La Pine Insurance Center: Commercial, Homeowners, Auto, Life & Health Insurance

We accept all policy changes by phone during business hours.

We recommend you contact our office if you have any questions about your coverage.

You may submit your policy change request to us by email. Changes are not in effect until notified by the agency or carrier. This in no way asserts or maintains that there is coverage available on your policy, that the change is acceptable by the insurer, or places a binder on any such coverage. If you submit a request and are not contacted within 1 business day please follow up by contacting our agency.

Personal Information
Name:
Address Line #1:
Address Line #2:
City:
State/Province:
Country:
Zip/Postal Code:
Day Time Phone Number:
Night Time Phone Number:
Best Time To Call:
E-Mail Address:
Preferred Merthod Of Contact:

Current Insurance Information
Company Name:
Policy Number:

Type Of Change
I Wish To:
Please fill out the appropriate form below.
Automobile Information
Make:
Model:
Year:
Body Type:
Name Of Title Holder:
Vehicle ID (VIN):
This Automobile Is Driven To Work/School:	Miles
This Automobile Contains Airbags:
This Automobile Has An Alarm:
If This Automobile Is Not Kept At The Above Adress, Please Provide The Information Below:
City: State: Zip:

Deductibles & Miscellaneous
Comprehensive Deductible	Collision Deductible	Towing	Loss Of Use

Driver Information
Name	Relation	Date Of Birth	Sex

Marital Status	Courses Completed In The Last 3 Years

Driver License Information
License Number:		State:	Years Licensed:

Driver History
Please list ANY convicitons for ANY moving traffic violation in the past 3 years.
Date Of Incident	Type Of Conviction		Speed Over The Limit
			mph
			mph
			mph
			mph
Please list ANY license suspensions, revocations, or driving under the influence convicitons.
License Suspended Or Revoked?		D.U.I. Conviction For?




Please list ANY accidents, regardless of fault, in the past 5 years.
Date	Description	Cost	Injuries / At Fault
		$
		$
		$
		$

Change Of Lienholder
Change The Lienholder On My:
Name:
Address Line #1:
Address Line #2:
City:
State/Province:
Country:
Zip/Postal Code:
Loan Number:

Additional Comments
Please leave any comments or additional information here.

I understand that by clicking the policy change request button below that changes are not in effect until notified by the agency or carrier. This in no way asserts or maintains that there is coverage available on your policy, that the change is acceptable by the insurer, or places a binder on any such coverage.

If you have not heard from our office in 24 hours during the week, or the next business day in the case of a weekend, please contact us by phone.

Our History | Our Staff | What You Can Expect | Driving Directions
Associations/Memberships | Contact Us

PO Box 778 ~ 51379 South Hwy 97

La Pine, Oregon 97739

Phone: 541-536-1718 or 800-506-1718

Fax: 541-536-5032 / Email: info@lapineins.com