Quote Form (Renters-AUTO)

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

Let's Make Your Quote Quick & Easy!

To help us get started on your quote, please have the following ready:
- A clear photo of your Driver’s License
- Photos of your vehicle(s) (front, back, and sides)
- 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
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
Date
Phone Number
Please enter a valid phone number.
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
Date
Gender
Email
example@example.com
Marital Status
Phone Number
Please enter a valid phone number.
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
Date
Gender
Email
example@example.com
Marital Status
Phone Number
Please enter a valid phone number.
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
Date
Gender
Email
example@example.com
Marital Status
Phone Number
Please enter a valid phone number.
Highest Level of Education
Is Member 4 Studying or Employed?
Is Member 4 Licensed (Including Suspended or Revoked?
Driver License
Occupation / Work Information

Unit Information
Total Household Asset
Total Household Income
Year Built
Deductible
Personal property Desired
Scheduled Personal Property
What is Your Scheduled Personal Property
Is the Fire Department Within 5 Miles From Your Unit?
Is the Hydrant Within 1000 ft From Your Unit?
Type Of Rental Unit
Total Sq. Ft
Any Animals Or Pet In The House
Has The Animal Bitten Previously or Acted Vicious or Aggressive?

Vehicle / Coverage Information

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

MonthDayYear
Date
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
Date
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
Date
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
Date
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

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By submitting, I acknowledge that I am requesting an insurance quote and authorize RMB Insurance Agency to obtain my credit and loss history reports.
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