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




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Awarded "Business of the Year" for 2008
by the La Pine Chamber of Commerce!

La Pine Insurance Center: Request a Change

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.

 

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La Pine Insurance Center

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