Are you a full time student under 25 carrying a (B) average or better? No Yes
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? No Yes

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:
15k/30k/5k 15k/30k/10k 25k/50k/25k 50k/100k/50k 100k/300k/100k

Uninsured Motorist:
15k/30k 25k/50k 50k/100k 100k/300k

Medical:
1,000 2,000 5,000

Comprehensive Deductible (coverage includes fire theft and vandalism):
Vehicle 1: None 100 Ded. 250 Ded. 500 Ded. 1000 Ded.
Vehicle 2: None 100 Ded. 250 Ded. 500 Ded. 1000 Ded.
Vehicle 3: None 100 Ded. 250 Ded. 500 Ded. 1000 Ded.
Vehicle 4: None 100 Ded. 250 Ded. 500 Ded. 1000 Ded.

Collision Deductible:
Vehicle 1: None 100 Ded. 250 Ded. 500 Ded. 1000 Ded. 2500 Ded. 5000 Ded.
Vehicle 2: None 100 Ded. 250 Ded. 500 Ded. 1000 Ded. 2500 Ded. 5000 Ded.
Vehicle 3: None 100 Ded. 250 Ded. 500 Ded. 1000 Ded. 2500 Ded. 5000 Ded.
Vehicle 4: None 100 Ded. 250 Ded. 500 Ded. 1000 Ded. 2500 Ded. 5000 Ded.

Towing:
Vehicle 1: Yes No
Vehicle 2: Yes No
Vehicle 3: Yes No
Vehicle 4: Yes No

Rental Car Coverage:
Yes No

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CONTACT US
Office: 916.361.8114
Fax: 916.366.6415
Toll - Free: 800.398.4246
Email: Click Here

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706 56th Street, Suite 150
Sacramento, CA 95819

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