Quote Form (HOME-AUTO)

Thanks for reaching out! We’re excited to help you protect what matters.

Let's Make Your Quote Quick & Easy!

Getting started on your quote, please have the following ready to hlep answer questions faster:
- A clear photo of all household member's Driver License
- Your current insurance declarations page (if available)
- For home insurance: property address, year built, roof age, and any recent upgrades
- For auto insurance: vehicle VIN numbers and list of all drivers in the household
- (Optional for Qutoe) Photos of your vehicle(s) (front, back, and sides)
The more details you provide, the smoother and faster we can get your personalized quote back to you. Thank you!

PERSONAL INFORMATION
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Highest Level of Education
Driver License
Occupation / Work Information
Gender
Marital Status
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Time Lived at Current Address
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Add Additional Household Member?

Member 2 Personal Information
Name

First NameLast Name
Relationship to the Insured
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Email
example@example.com
Marital Status
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Highest Level of Education
Is Member 2 Studying or Employed?
Is Member 2 Licensed (Including Suspended or Revoked?
Driver License
Occupation / Work Information
Add Additional Household Member?

Member 3 Personal Information
Name

First NameLast Name
Relationship to the Insured
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Email
example@example.com
Marital Status
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Highest Level of Education
Is Member 3 Studying or Employed?
Is Member 3 Licensed (Including Suspended or Revoked?
Driver License
Occupation / Work Information
Add Additional Household Member?

Member 4 Personal Information
Name

First NameLast Name
Relationship to the Insured
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Email
example@example.com
Marital Status
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Highest Level of Education
Is Member 4 Studying or Employed?
Is Member 4 Licensed (Including Suspended or Revoked?
Driver License
Occupation / Work Information

Home Information
Year Built
Deductible
Home Purchase / Closed Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Number
Foundation Type
Basement Type
Percentage of Basement Finished
Number if Full Bathroom
Does Your House Have Central Air?
Do you have a Fireplace?
Does Your House Have a Security System?
Type of Security System
If Other, Please Specify
Years of Updates
SIze of the Deck
Dwelling Under Construction?
Garage Type
How Many Stalls?
Type of Roof
Roofing Materials
Type of Siding
Do You Have a Simming Pool or Hot Tub?
Type a question
Electrical Amps
Scheduled Personal Property
What is Your Scheduled Personal Property
Out of Buildings or Shed

Vehicle / Coverage Information

Vehicle 1
Name(s) Listed on Vehicle 1 Title
Odometer
Vehicle 1 Purchase Price
Purchase Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Vehicle 1 Use
Vehicle 1 Leased or Financed?
Vehicle 1 Information
Finance or Leasing Company
Vehicle 1 Liability Limits
Choose Auto Coverage
Deductibles
Auto Glass Coverage
Towing Coverage
Rental Car Coverage
Vehicle 1 Be Used For Delivery or Ride Share
If Yes, Please Explain
Vehicle 1 Have Custom Equipment or Non-Factory Equipment
Does Vehicle 1 Have Salvaged Title?
Do you need to add a vehicle

Vehicle / Coverage Information

Vehicle 2
Name(s) Listed on Vehicle 2 Title
Odometer
Vehicle 2 Purchase Price
Purchase Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Vehicle 2 Use
Vehicle 2 Leased or Financed?
Vehicle 2 Information
Finance or Leasing Company
Vehicle 2 Liability Limits
Choose Auto Coverage
Deductibles
Auto Glass Coverage
Towing Coverage
Rental Car Coverage
Vehicle 2 Be Used For Delivery or Ride Share
If Yes, Please Explain
Vehicle 2 Have Custom Equipment or Non-Factory Equipment
Does Vehicle 2 Have Salvaged Title?
Do you need to add a vehicle

Vehicle / Coverage Information

Vehicle 3
Name(s) Listed on Vehicle 3 Title
Odometer
Vehicle 3 Purchase Price
Purchase Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Vehicle 3 Use
Vehicle 3 Leased or Financed?
Vehicle 3 Information
Finance or Leasing Company
Vehicle 3 Liability Limits
Choose Auto Coverage
Deductibles
Auto Glass Coverage
Towing Coverage
Rental Car Coverage
Vehicle 3 Be Used For Delivery or Ride Share
If Yes, Please Explain
Vehicle 3 Have Custom Equipment or Non-Factory Equipment
Does Vehicle 3 Have Salvaged Title?
Do you need to add a vehicle

Vehicle / Coverage Information

Vehicle 4
Name(s) Listed on Vehicle 4 Title
Odometer
Vehicle 4 Purchase Price
Purchase Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Vehicle 4 Use
Vehicle 4 Leased or Financed?
Vehicle 4 Information
Finance or Leasing Company
Vehicle 4 Liability Limits
Choose Auto Coverage
Deductibles
Auto Glass Coverage
Towing Coverage
Rental Car Coverage
Vehicle 4 Be Used For Delivery or Ride Share
If Yes, Please Explain
Vehicle 4 Have Custom Equipment or Non-Factory Equipment

Additional Questions
Preferred Payment Option
Current Insurance provider
Length of time with Current Insurance Provider
RMBIA Service Rep Fill out this form?
Any Additional Notes of Comments?
Upload Photos, Files or Documents

Cancelof
Please verify that you are human
By submitting, I acknowledge that I am requesting an insurance quote and authorize RMB Insurance Agency to obtain my credit and loss history reports.
Should be Empty: