C.H. Edwards, Inc.
      791 South Main Street
      Farmingdale, NY  11735        E-Mail: Info@chedwards.net
                                                                       Telephone:  516 249-5200    Fax: 516 249-5255
     



 

New York

On-Line Defensive Driver Course  click here to save 10% on your auto insurance

 

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Beachfront, Bulkhead, Shoreline

 

All qualify Vacant/Seasonal OK

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& a specific rate quote

 

(516)249-5200

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©2003, C.H. Edwards. All rights reserved.

791 South Main Street, Farmingdale, N.Y. 11735
Phone: (516) 249-5200
Fax: (516) 249-5255
 
   

Automobile Insurance Quote Request

This process will allow you to request a quote for up to 4 vehicles and 4 drivers.
Please remember that the more information provided, the more accurate the quote we provide will be. The fields marked in red are required.

This is some information you should have available to complete the form:

   1) Year/Make/Model or VIN for each vehicle
   2) Name/Date of Birth for each driver
   3) Accidents/Violations within the last 36 months

Note:  Items marked in red are required items and must be answered prior to clicking submit.

Referrer's Name:
Name: Phone:
Address: E-Mail:
City: State: SS#:
Spouse: Spouse SS#
Single/Married:Married  Single 
Children:Yes  No   Driving: Yes No  Age(s):

Driver Information
     
Driver #1

 
DOB:
 License#
 Occupation: Employer:
Defensive Driver TrainingYes No
 
Driver #2
DOB:
 License#
 Occupation: Employer:
Defensive Driver TrainingYes No  
 
Driver #3  
DOB:
 License#
 Occupation: Employer:
Defensive Driver TrainingYes No  
 
Driver #4      
DOB:
 License#:
 Occupation: Employer:
Defensive Driver TrainingYes No    
 
Tickets in the last 39 months?  Yes No

DWI in the last 10 years?  Yes No

Prior 6 month insurance? Yes No    Company: 
Effective Dates:

    
Vehicle Information
Vehicle #1
Year Make Model VIN#
Miles Driven To Work  Air Bag Yes No,  1 or 2
ABS:  YesNo DRL: YesNo Alarm:YesNo Type:

Antilock Braking System     Daytime Running Lights 
      
Vehicle #2      
Year Make Model VIN#
Miles Driven To Work Air Bag Yes No, 1  or 2  
ABS: YesNo DRL:  YesNo Alarm:YesNo Type:
Antilock Braking System      Daytime Running Lights

     
Vehicle #3
Year Make Model VIN#
Miles Driven To Work Air Bag Yes No, 1  or 2
ABS:Yes No DRL: YesNo Alarm: YesNo Type:
Antilock Braking System      Daytime Running Lights
     
Vehicle #4
Year Make Model VIN#
Miles Driven To Work Air Bag Yes No, 1  or 2  
ABS:Yes No DRL: YesNo Alarm:  YesNo Type:
Antilock Braking System      Daytime Running Lights

Coverage Desired  

Vehicle #1

Liability:Collision Deductible: Comprehensive Deductible:

Vehicle #2
Liability:Collision Deductible:
Comprehensive Deductible:


Vehicle #3
Liability:Collision Deductible: Comprehensive Deductible:


Vehicle #4
Liability:Collision Deductible:Comprehensive Deductible:

 

Please ensure that all questions in red have been answered prior to clicking submit. 

                           
                                

 

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