Personal - Business - Life & Health

Proudly Serving Upstate New York Since 1897!

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Please fill out the below form if you would like us to contact you directly to start an insurance quote.

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Get A Quote

To obtain a quote, simply complete the appropriate Homeowners, Auto, or Renters questionnaires below and click "Submit". We will get back to you shortly to review your quote.

Life Insurance

Currently have a policy and looking at options to replace it? The team at Specific Solutions will do a complete policy review and recommend replacement options for FREE. Just complete the two-page Policy Authorization Form and mail/fax/email us a copy and we will take care of the rest.

Mail: 258 North Street, Caledonia, NY 14423
Fax: 585-538-2847
Email: info@calbranch.com

First Name: Last Name:
Date of Birth: Phone #
Email: Gender:
Amount of Insurance: Desired Length:

Optional Riders:

Accidental Death Benefit YesNo

Waiver of Premium Yes No

Return of Premium Yes No

Child Rider(s)

Health Profile

Ever used tobacco or other nicotine products?
What type of tobacco or nicotine product?
How many cigarettes per day?
How many cigars per day?
Height
Weight
 
 


Auto Insurance

Primary Insured Name*Spouse Name
Address*
City, State Zip*
Garaging Address(if different)
Garaging City, State Zip
Date of BirthSpouse Date of Birth
Home Phone*Alt Phone(cell)
Work Number
Email AddressSpouse Email
OccupationSpouse Occupation
Own or Rent HomeSpouse Work Number
Social Security NumberSpouse SSN
Current Auto InsuranceRenewal Date

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3
4
5
Credit and Clue reports enchance the accuracy of the quotes. Authorization to run these reports?

Driver History

Any accidents in the last 6 years?Yes No
Any minor moving violations (tickets) in last 6 years?Yes No
Any major violations (2 points) the last 6 years?Yes No
Please explain any Yes answers below. Include dates, type of violation and whether you were at fault.

Vehicles

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3
4
5
Any non standard (non factory) installed rims or other enchancements or special paint jobs? If yes, please describe:
Check any cars with anti-lock brakes on all 4 wheels:1 2 3 4 5
Check any cars with air bags:1 2 3 4 5
Do any drivers under 25yrs have a "B" or higher average with full time school status?Yes No
if Yes, driver(s)
List any drivers who took a defensive driving course in the last 3 years
List any drivers who took a driver training course

Coverage Limits

Bodily Injury Liability (Per Person/Per Accident)
Uninsured Motorist (Per Person/Per Accident)
Comprehensive (Other than Collision) Deductible
Property Damage
Medical payments
Collision Deductible
Towing/Road AssistanceYes No
Rental Car ReimbursementYes No
If yes, how much per day?
If you have a copy of your declaration page(s) outlining your current coverage, please include when submitting
 
 

Home Insurance


Primary Insured Name*Spouse Name
Address*
City, State Zip*
Date of BirthSpouse Date of Birth
Social Security NumberSpouse SSN
Home Phone*Work Phone
EmailOccupation
Current Home InsuranceRenewal Date

2
3
4
Credit and Clue reports will be run when quoting. Do you authorize agents to run these?

Dwelling Information

Residence TypeOccupancy
Year BuiltSquare Feet
Replacement Cost (if known)
Pets?If yes, list kind/breed
Distance to Fire Hydrant (feet)Distance to Fire Station (miles)
Years of updates:
PlumbingHeating
Electrical
# StoriesStyle (colonial,split level,etc)
Roof TypeRoof Age (years)
Garage TypeGarage # of cars
Basement?If yes, square feet
If finished, what %?
# of Full Bathrooms# of Half bathrooms
Swimming Pool?If yes, gated and locked?
Deck?Square Footage
Deck Material
Porch?Square Footage

Discount Questions

Non-SmokerDead Bolt Locks on All Exterior Doors
Fire ExtinguisherSmoke Detectors/Alarms
Burglar AlarmInterior Fire Sprinklers
Energy Source All ElectricEnergy Source All Solar

Any claims in the last 3 years? If yes, please outline briefly below the date of the loss, the type of loss (vandalism, theft, etc), and the amount of payout for each loss. Yes No
Interior Walls: Drywall Plaster
Cathedral Ceiling:   Yes No
If yes, what %
Kitchen: Standard Custom Luxury
Laundry room?Yes No If yes, which floor?

% Exterior Walls (provide percentages, needs to equal 100%)
Alum/Vinyl Siding
Asbestos Shingles
Cement Shingles
Clapboard
Stucco on Masonry
Stucco
Wood Shakes
Wood Siding
Brick Veneer
Stone Veneer
% Interior Walls (provide percentages, needs to equal 100%)
Bookcase Walls
Brick Facing
Ceramic Tile
Foil Wallpaper
Grass Cloth Paper
Imported Ceramic Tile
Marble
Mirrors
Paint
Sheet Paneling
Solid Wood Paneling
Vinyl Wallpaper
% Flooring (provide percentages, needs to equal 100%)
Brick
Carpet (Std)
Carpet (Custom)
Carpet Over Hardwood
Ceramic Tile
Custom Carpet Over Hardwood
Hardwood
Imported Ceramic Tile
Laminated
Marble
Parquet
Slate
Stone
Vinyl

Wood Burning Fireplace/Stove:Yes No
How many?
Any located in garage/barn?Yes No
Heating/Cooling:Heating and A/C Heating Only
Foundation:
Plumbing:
All Copper?Yes No
If No, what kind of plumbing?
Electrical:
Circuit Breakers?Yes No
AMP capacity of electrical panel?
Type of Heating System?
(forced air, baseboard, etc)
Secondary Heating System?Yes No
If yes, system type:
Policies have limitations on certain property such as computers and jewlery. Are there valuable item you want to ensure are covered? If so, please briefly describe below and value each item.
Deductible(s) you would like
to have quoted ($100 - $1,000 etc)
If this is a home purchase:
Close Date(approx):
Will the current owner be renting back?Yes No
If yes, for how long?
Flood Insurance Quote?Yes No
If yes, flood zone # (if known)
Other insurance needs (auto, life, health or disability, or long term) If so, please list here.
 

Renters Insurance


Primary Insured Name*Spouse Name
Address of House*
City, State Zip*
Date of BirthSpouse Date of Birth
Social Security NumberSpouse SSN
Home Phone*Work Phone
EmailOccupation
Current Renters InsuranceRenewal Date

2
3
4
Credit and Clue reports enchance the accuracy of the quotes. Authorization to run these reports?

Renters Information

Pets or Exotic Animals?Yes No
If yes, list kind and breed
Distance to Fire Hydrant (feet)
Distance to Fire Station (miles)
Type of Residence:
Number of Stories:
parking:
Amount of coverage requested for
your Personal Property (min $15,000)
Personal Liability coverage requested (min $100,000)
Basement?Yes No
If yes, are you interested in coverage
for water and sewer back-up?
Yes No
Swimming Pool?Yes No
If yes, gated and locked?Yes No

Discount Questions

Non-SmokerDead Bolt Locks on All Exterior Doors
Fire ExtinguisherSmoke Detectors/Alarms
Burglar AlarmInterior Fire Sprinklers

Any Claims in the last 3 years?
If yes, please outline briefly below the date of the loss, the type of loss (vandalism, theft, etc.) and the amount of payout for each loss.
Policies have maximum dollar limitations on certain property such as computers and jewlery. Are there valuable items you want to ensure?
If yes, please briefly describe below and monetary value for each.
Deductible(s) you would like to have quoted ($100 - $1,000)
Other Insurance needs (auto, life, health or disability, or long term care) If so, please list here