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Home/Renters Insurance

RMI Insurance Services is a multi-line insurance agency specializing in providing low wholesale prices for both commercial and personal customers. We represent a huge array of insurance companies who can provide you with comprehensive coverage for all your insurance needs. If you've been turned down by another company or your rates are too high - give us a try!

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Personal Information
Name:
Mailing Address:
City:
State:
Zip:
Home Phone:
Business Phone:
Email:

About Your Home If the property to be insured is different than your current address what is the mailing address of the property to be insured?
Street Address:
City:
State:
Zip:
1. Dwelling's Current limit of Insurance:
2. Square Footage W/O Garage:
3. Year Built:
4. Number of Units:	Single Family	Duplex
	Triplex	Fourplex
5. Number of Stories:	One	Two
	Three+
6. Construction Type:	Frame	Masonry
7. Occupancy:	Primary	Secondary
	Tenant	Seasonal
8. Roof Type:	Composite	Tile
	Shake	Other
9. Liability Limit:	$300,000	$500,000
	$1,000,000
10. Medical Payments:	$500	$1,000
	$2,000	$5,000
11. Deductible:	$500	$1,000
	$1,500	$2,500
12. How many losses or claims have you had in the past 3 years?:	0	1
	2	3+
If any losses, we need date of loss, type of loss, amount paid on claim.
Date:
Type of Loss:
Amount Paid on Claim:
The insurance companies we write with run credit reports. In order to place you with the best company for you we need to know if you have any derogatory information on your credit report i.e. � bankruptcy, lien, judgments or collections.
13. Do you have any derogatory information on your credit report?:	Yes	No
	If yes details:
14. Is your Home Currently Insured?	Yes	No
15. Do you have any special requirements of your insurance?:	Jewelry	Guns
	Fine Art	Furs
	Other
16. Does Your Property Have a Garage?:	Yes	No
If Yes....	Attached	Detached
Number of Cars:	1	2
	3	4+
Rating Information Property Attributes
Over 1000 feet from a hydrant	FIRE STATION: Over 5 to 10 mi
FIRE STATION: Over 10 mi	Brush Hazard
Smoke Alarm	Fire Extinguisher
Deadbolts	SPRINKLERS: Partial
SPRINKLERS: Full	THEFT ALARM: Local
THEFT ALARM: Station	THEFT ALARM: Central
FIRE ALARM: Local	FIRE ALARM: Station
FIRE ALARM: Central	Gated Community
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