Auto Lease Rate Indicator
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  1. Agent Information
  2. Are you an agent?*
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  3. Name
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  4. Agency
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  5. Address
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  6. City
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  7. State
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  8. Zip
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  9. Phone
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  10. Fax
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  11. Email
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  12. Page 1 of 3
  13.  
  1. Insured Information
  2. Name
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  3. Company
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  4. DBA
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  5. Street Address
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  6. City
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  7. State
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  8. Zip
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  9. Phone
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  10. Fax
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  11. Email
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  12. Page 2 of 3
  13.  
  1. Policy Information
  2. Years in Operation
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  3. Policy Effective Date
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  4. Number of Vehicles (#)
  5. Private Passenger
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  6. Trucks GVW 12,500+
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  7. Mini Vans
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  8. 15 Psgr Vans
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  9. Other
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  10. Current Coverage ($)
  11. Please provide whole number, excluding ($) symbol.
  12. Liability Limit
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  13. Physical Damage Deductible
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  14. Current Annual Premium
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  15. Current Carrier
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  16. Loss History ($)
  17. Please provide whole number, excluding ($) symbol.
  18. Current Year
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  19. One Year Prior
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  20. Two Years Prior
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  21. Total Losses
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  22. Page 3 of 3

Program Contact

Rich O'Connor
Program Manager
845-534-5587 Direct
845-534-5130 Fax
This email address is being protected from spambots. You need JavaScript enabled to view it.

Program Overview

  • Liability up to $1,000,000 CSL
  • Excess Liability over $1,000,000 available
  • Physical Damage
  • Interim Car Coverage

PDF Download

©2011 - 2013 GMI Insurance - All Rights Reserved. Information contained within this website should NOT be interpreted as to bind, add or delete coverage of any GMI Insurance Program and is subject to change without notice.


Mailing Address: P.O. Box 701, Valley Forge, PA 19482 | Physical Address: 99 Starr Street, Phoenixville, PA 19460
Phone 1-610-933-4679 • Fax 1-610-933-4993 • Toll-Free 1-800-722-3229 • Email This email address is being protected from spambots. You need JavaScript enabled to view it.