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

We welcome the opportunity to provide you a quote on all your insurance needs.

Please fill out the complete form below if you wish us to return a completed quote to you.

If you just desire us to contact you please fill out all the personal information through "preferred method of contact".

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 Method Of Contact:
Occupation:
How Long At Present Job:
SS/SIN Number:
In order to correctly process your quote form it may be necessary for us to obtain a consumer report on your behalf. By clicking the submit form below I authorize the company to obtain and review this report.
Have you had any judgements, liens, or bankruptcies in the last 7 years?	If you are a resident of California please do not answer this question.
If yes to the above question please explain just below. If you are a resident of California please do not answer this question.

Current Insurance Information
Company Name:
Policy Expiration:
Premium Amount:	$ (Optional)
Current Coverage Or Bodily Injury Amount:	$
Continuously Insured For The Last:
Have you ever had insurance cancelled, denied, or non-renewed?
If yes why?

Home Information
How Long At Your Present Address:
The Year Your Home Was Built In:
Square Footage NOT Including Garage Or Basement:	sq. ft.
Square Footage Of First Floor:	sq. ft.
Square Footage Of Second Floor:	sq. ft.
# Of Claims In The Last 3 Years:
Structure Information
Type:
Construction:
Foundation:
Roof Type:
Roof Age:	years
Garage Size:
Garage Type:
Square Footage Of Deck:	sq. ft.
Square Footage Of Porch:	sq. ft.
Square Footage Of Patio:	sq. ft.
Number Of Fireplace Chimneys:
Number Of Fireplace Hearths:
Number Of Full Bathrooms:
Number Of Half Bathroooms:
State Of Basement:
Square Footage Of Basement:	sq. ft.
Additional Features
Heating System:
Central Air:
Central Vacuum:
Security Alarm:
Fire Alarm:
Smoke Detector:
Pets.
Do You Have Any Pets?
If yes to the above question, please completely describe all of your pets below. Including type and breed.
Coverage Desired.
Amount On Dwelling?	$
Amount On Contents?	$
Amount Of Other Structures?	$
Replacement Value?	$

Additional Comments
Please leave any comments or additional information here.

By clicking the submit button below I agree to understand that this is for quote purposes only and in no way acts and an application or binder of insurance.

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