Landlord / Dwelling Fire Insurance Inquiry Form

Applicant 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
Property Address (to be insured)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this a rental property?
How many units are in this property?
How is the property used?
If Other, please specify
Property Details
Year Built
Square Footage:
Construction Type:
Roof Type and Age
Foundation Type
If other, please specify
Heating Type
If other, please specify
Year of Update
Coverage Preferences
Type of Dwelling Policy Preferred
Desired Dwelling Coverage Amount
Personal Property Coverage (if any)
Loss of Rental Income Coverage
Liability Coverage Amount
If Other, please specify
Current Insurance Info
Do you currently have landlord insurance?
If Yes, please list the Insurance Carrier
Policy Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Any claims in the last 5 years?
If yes, Please explain
Additional Notes or Comments
Upload Photos, Files or Documents

Cancelof
RMBIA Service Rep Fill out this form?
Have you read the terms and conditions to them?
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.
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Applicant Information