RMI Agency's Auto & Home Insurance Quote Form
To apply for an Auto insurance quote complete all required fields. An agent will get back to shortly! Most of the information used for an auto quote we need to use for your homeowners quote. If you are just looking for home, just type in N/A under vehicle info.
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Drivers License Number?
*
Specify State Issue ex: AL, FL, LA
E-mail
*
The one that you prefer to be contacted on for all things related to your quote submission and policy. We have send e-signatures to bind coverage.
Phone Number
*
Current Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Preferred Method of Contact?
*
Please Select
Email only
Call Me
Text Only
If we have questions, we want to know the best way to get ahold of you.
Do you Own or Rent your Home?
*
It's crucial for us to know. Some of our carriers will allow us to apply a homeowner discount without requiring you to swap homeowners carriers.
Spouse Name (if none- please leave blank)
First Name
Last Name
Spouse Date of birth
-
Month
-
Day
Year
Date
Spouse Drivers License Number? (if none- please leave blank)
It's crucial to list your spouse on your policy so they are covered! And for DISCOUNTS! If you need to list them but are having a hard time retrieving the DL number.(life gets busy, we get it!) Don't worry! Type in "11111111" for now. We'll need it soon though!
Teenage Driver(s) (if none- please leave blank)
First Name
Last Name
Teen Drivers License Number?
For Permit Teen Drivers they are still given a license number. Type "P" to specify before typing.
Back
Next
Do you need to bundle your Auto Policy with Home-Boat-RV-Motorcycle?
*
yes
no
Are all applicable drivers listed on this form?
*
yes
no
Who is your Auto Insurance currently with?
*
Please Select
Geico
Lapse/No Prior Coverage HELP
Progressive Online
Progressive Local Agent Handles It
State Farm
National General
Encompass
Acceptance
Direct Auto
Auto Owners
Alfa
Independent Agency(not sure who)
Country Financial
Farmers
Bristol West
Dairyland
Allstate
Travelers
Other Not Listed
The only reason we ask is because we use over 50 insurance carriers. It helps us streamline your quote by not quoting with the same carrier you have now!
Current or Requested Bodily Injury Limits/Property Damage
*
Please Select
None help!
Not sure, whatever you think is best
I have no clue whatever my state allows
25/50/25
50/100/50
100/300/100
250/500/250
What are you paying monthly for your auto insurance?
*
You can upload your current Auto insurance pages for us to review coverages! Optional
Browse Files
Drag and drop files here
Choose a file
Most carriers have this information on their App or your account. Look for "my coverages or declarations" Save to phone or desktop then upload. This is optional.
Cancel
of
Deductible Preference
*
Please Select
500 comp/collision
1000 comp/collision
I just need liability
Vehicle 1: Year, Make, Model (optional: Vin #)
*
Do you want full coverage on Vehicle 1?
*
yes
no
Vehicle 2: Year, Make, Model (optional: Vin #)
Do you want full coverage on Vehicle 2?
yes
no
Vehicle 3: Year, Make, Model (optional: Vin #)
Do you want full coverage on Vehicle 3?
yes
no
Is there anything else you would like a quote on? When you have your home and auto insurance together you can save up to 35%!
*
Home
Condo
Renters
No thanks I am all set!
Commercial Auto
RV
Business
Motorcycle
Boat
Off-road Vehicle
Something else
If your vehicle(s) are financed we will need to list the bank on the policy.
*
Just type in the name of the financial institution for each vehicle. We most likely have their address already. If not we'll verify with you later.
Most of our clients are setup on automatic monthly draft from a bank account or debit/credit card. These are the cheaper options next to paying in full. What day of the month does your current payment come out?
*
We only ask as a courtesy. We want to make sure our effective dates on the quotes line up with when you are used to paying!
How soon do you need coverage?
*
Please Select
NOW (if selected we will expedite)
1-2 Days
Next Week
Next Month
Do you need a life insurance quote as well?
*
a little bit of life insurance is better than none!
Do you need a Health Insurance Quote?
*
yes or no
Do you need Dental or Vision?
*
yes or no
Apply for quote
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