Referrer Information

Full Name *

Phone *

Email *

Referral Type

Referred Person Information

Referred Person’s Full Name *

Referred Person’s Email Address *

Referred Person’s Phone Number *

Relationship to You

Reason for Referral / Notes

By providing my phone number and submitting this form, I expressly consent to receive phone calls and SMS/text messages from RMB Insurance Agency (and its agents or affiliates). I understand that these communications may be automated, prerecorded, or use an AI-generated voice, and may include marketing, promotional, and insurance offers. I acknowledge that I do not have to consent as a condition of purchasing any product or service. I may revoke this consent at any time by replying “STOP,” calling (507) 424-1044, or emailing [email protected] .

I agree to RMBIA’s Privacy Policy and understand how this information will be used.