RMI Insurance - Automobile Insurance

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Automobile Insurance

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Personal Information
First Name:
Last Name:
Garaging Address:
Garaging City
State:
Zip:
Home Phone:
Business Phone:
Fax Phone:
Note: You will not be contacted via telephone unless you indicate this as a preference at the bottom of this form.
Email:

About the Drivers If more than 4 drivers, please provide information in the area provided for comments at the bottom of this page.
Driver 1 Name:
Sex:
Marital Status:
Years of Licensed in North America:
Date of Birth:	//
Full Time Student?:
If Student, 3.0 GPA or Higher?:

About the Drivers If more than 4 drivers, please provide information in the area provided for comments at the bottom of this page.
Driver 2 Name:
Sex:
Marital Status:
Years of Licensed in North America:
Date of Birth:	//
Full Time Student?:
If Student, 3.0 GPA or Higher?:

About the Drivers If more than 4 drivers, please provide information in the area provided for comments at the bottom of this page.
Driver 3 Name:
Sex:
Marital Status:
Years of Licensed in North America:
Date of Birth:	//
Full Time Student?:
If Student, 3.0 GPA or Higher?:

About the Drivers If more than 4 drivers, please provide information in the area provided for comments at the bottom of this page.
Driver 4 Name:
Sex:
Marital Status:
Years of Licensed in North America:
Date of Birth:	//
Full Time Student?:
If Student, 3.0 GPA or Higher?:

About the Cars - Vehicle 1 Please be specific (for example, Year: 1991, Make: Honda, Model: CRX Si) For the most accurate quote, please include Vehicle Identification Number (VIN). If more than 4 vehicles, please provide information in the area provided for comments at the bottom of this page.
Year:
VIN:
Make:
Model & Sub Model:
4 Wheel Drive:
Miles One Way to Work:
Annual Miles Driven:
Vehicle Used Only for Pleasure?:

About the Cars - Vehicle 2 Please be specific (for example, Year: 1991, Make: Honda, Model: CRX Si) For the most accurate quote, please include Vehicle Identification Number (VIN). If more than 4 vehicles, please provide information in the area provided for comments at the bottom of this page.
Year:
VIN:
Make:
Model & Sub Model:
4 Wheel Drive:
Miles One Way to Work:
Annual Miles Driven:
Vehicle Used Only for Pleasure?:

About the Cars - Vehicle 3 Please be specific (for example, Year: 1991, Make: Honda, Model: CRX Si) For the most accurate quote, please include Vehicle Identification Number (VIN). If more than 4 vehicles, please provide information in the area provided for comments at the bottom of this page.
Year:
VIN:
Make:
Model & Sub Model:
4 Wheel Drive:
Miles One Way to Work:
Annual Miles Driven:
Vehicle Used Only for Pleasure?:

About the Cars - Vehicle 4 Please be specific (for example, Year: 1991, Make: Honda, Model: CRX Si) For the most accurate quote, please include Vehicle Identification Number (VIN). If more than 4 vehicles, please provide information in the area provided for comments at the bottom of this page.
Year:
VIN:
Make:
Model & Sub Model:
4 Wheel Drive:
Miles One Way to Work:
Annual Miles Driven:
Vehicle Used Only for Pleasure?:

Driving History - Driver 1 Please provide accurate information for: last 3 years (Minors - speeding, etc.) last 5 years (Majors - drunk driving, reckless, hit & run, etc.)
No. of Minor Violations:
Dates
No. of Major Violations:
Dates
No. of Accidents (Not At Fault):
Dates
No. of Accidents (At Fault w/o Bodily Injury):
Dates
No. of Accidents (At Fault with Bodily Injury):
Dates
Driving History - Driver 2
No. of Minor Violations:
Dates
No. of Major Violations:
Dates
No. of Accidents (Not At Fault):
Dates
No. of Accidents (At Fault w/o Bodily Injury):
Dates
No. of Accidents (At Fault with Bodily Injury):
Dates
Driving History - Driver 3
No. of Minor Violations:
Dates
No. of Major Violations:
Dates
No. of Accidents (Not At Fault):
Dates
No. of Accidents (At Fault w/o Bodily Injury):
Dates
No. of Accidents (At Fault with Bodily Injury):
Dates
Driving History - Driver 4
No. of Minor Violations:
Dates
No. of Major Violations:
Dates
No. of Accidents (Not At Fault):
Dates
No. of Accidents (At Fault w/o Bodily Injury):
Dates
No. of Accidents (At Fault with Bodily Injury):
Dates

Limits of Liability
Bodily Injury:
Property Damage:
Uninsured Motorist/Bodily Injury:
Uninsured Motorist Property Damage Waiver:
Medical Payments:

Deductibles
Vehicle 1
Do you want Physical Damage coverage?
Comprehensive:
Collision:
Vehicle 2
Do you want Physical Damage coverage?
Comprehensive:
Collision:
Vehicle 3
Do you want Physical Damage coverage?
Comprehensive:
Collision:
Vehicle 4
Do you want Physical Damage coverage?
Comprehensive:
Collision:

Additional Endorsements & Misc. Information
Towing & Roadside Service:
Rental Car Reimbursement:
SR-22 Filing Needed:
Do you currently carry Liability coverage?:
If so, how long insured without a lapse in coverage?:	Years Months
Name of Current Insurance Company:	(optional)
Expiration Date of Current Policy:	(optional)
Current Premium:	(optional)
Would you like to be contacted via telephone?:
Would you like to be contacted via fax?:
Association Name?:
Alarm?:
Questions, Comments or Additional Information:
How Did You Hear About Us?:

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