Styrsky Insurance Sacramento; Auto, Home and Life Company

Phone: 916.361.8114
Toll Free: 800.398.4246
Fax: 916.366.8706
Email: office@styrskyinsurance.com

For a free quote give us For a free quote give us a call, Email Us or fill out this form and we will contact you shortly.

Name
Address
City
State
Zip
Email
Telephone

Driver #1 DOB	Sex	Marital Status
Driver #2 DOB	Sex	Marital Status
Driver #3 DOB	Sex	Marital Status
Driver #4 DOB	Sex	Marital Status

Are you a full time student under 25 carrying a (B) average or better?
Do you currently have auto insurance? If yes, With whom are you presently insured?
How long have you been insured with your current company?

How old were you when you were first licensed?
Driver #1
Driver #2
Driver #3
Driver #4

What violations have you had in the last 3 year?
All drivers and the approximate date of the violations.

Do you need any special filing for SR22?

Vehicle #1

Year

Make

Model

Annual Milage

Vehicle#2

Year

Make

Model

Annual Milage

Vehicle #3

Year

Make

Model

Annual Milage

Vehicle #4

Year

Make

Model

Annual Milage

Please choose your liability limits:
The state requires bodily injury liability of at least 15/30/5. These limits are in thousands BL 15,000 per person,
30,000 per accident and 5,000 in property damage. We recommend much more!!!!!

Bodily Injury Limits:

Uninsured Motorist:

Medical:

Comprehensive Deductible (coverage includes fire theft and vandalism):
Vehicle 1:
Vehicle 2:
Vehicle 3:
Vehicle 4:

Collision Deductible:
Vehicle 1:
Vehicle 2:
Vehicle 3:
Vehicle 4:

Towing:
Vehicle 1:
Vehicle 2:
Vehicle 3:
Vehicle 4:

Rental Car Coverage:

Your Sacramento Insurance Company for Home, Auto Insurance, Health, and Life Insurance