Life Quote Form

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
Date
Gender
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have an active Life Policy?
Do you intend to replace your current Life Insurance Policy?
Current Life Insurance Policy Information
Occupation / Work Information
List the following:
Do you use tobacco or any smoking products?
Alcohol Use
Exercise Habit
Family Medical History
Are you on prescribed medication?
List Current Medication Prescribed
Medical History
Upload Documents, Photos, File

Cancelof
Additional Notes or Comments
RMBIA Service Rep Fill out this form?
Consent to Collect and Use Medical Information

I, the undersigned, acknowledge that I have applied for a life insurance policy with RMB Insurance Agency. I understand that in order to evaluate my application, [Insurance Company Name] may need to collect and use my medical information, including but not limited to my family medical history.

I hereby consent to the following:

1. Collection of Medical Information: I authorize RMB Insurance Agency and its representatives to collect my medical history, including any information about family medical history, from healthcare providers, insurance companies, or any other relevant sources.

2. Use of Medical Information: I understand that my medical information will be used solely for the purpose of underwriting my life insurance application and assessing risk.

3. Confidentiality: I acknowledge that RMB Insurance Agency will handle my medical information in accordance with all applicable privacy laws, including HIPAA, and that my information will remain confidential.

4. Right to Withdraw Consent: I understand that I have the right to withdraw my consent at any time by notifying RMB Insurance Agency in writing. However, this may affect the evaluation of my application.

Acknowledgment of Understanding

By signing below, I confirm that I have read and understand this consent and acknowledgment form, and I voluntarily agree to provide the necessary medical information for my life insurance application
Signature

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Date Signed

MonthDayYear
Date
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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Personal Information