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

Please fill out the form below to request a Certificate of Insurance.

If someone has not contacted you within 1 business day regarding your certificate please call our office.

This in no way asserts or maintains that there is coverage available on your policy, that the certificate is acceptable by the insurer, or places a binder on any such coverage.

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:

Certificate Recipient 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:

Additional Comments
Please leave any comments or additional information here.

I understand that by clicking the submit request button below that certificates 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 certificate is acceptable by the insurer, or places a binder on any such coverage.

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