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 properly quote this insurance it may become necessary obtain a consumer report on your behalf. By clicking the submit button I allow the agency to order any such reports.
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?

Motorcycle #1 Information
Make:
Model:
Year:
Motorcycle Type:
CC's:
Name Of Title Holder:
Vehicle ID (VIN):
Has This Motorcycle Been Modified?
If Yes To The Above Question, What Is The Value Of Modifications?	$
Is This A Custom Motorcycle?
If Yes To The Above Question, What Is The Appraised Value Of The Motorcycle?	$
This Motorcycle Is Driven To Work/School:	Miles
This Motorcycle Has An Alarm:
This Motorcycle Is Stored In:
If This Motorcycle Is Not Kept At The Above Adress, Please Provide The Information Below:
City: State: Zip:
Motorcycle #2 Information
Make:
Model:
Year:
Motorcycle Type:
CC's:
Name Of Title Holder:
Vehicle ID (VIN):
Has This Motorcycle Been Modified?
If Yes To The Above Question, What Is The Value Of Modifications?	$
Is This A Custom Motorcycle?
If Yes To The Above Question, What Is The Appraised Value Of The Motorcycle?	$
This Motorcycle Is Driven To Work/School:	Miles
This Motorcycle Has An Alarm:
This Motorcycle Is Stored In:
If This Motorcycle Is Not Kept At The Above Adress, Please Provide The Information Below:
City: State: Zip:
Motorcycle #3 Information
Make:
Model:
Year:
Motorcycle Type:
CC's:
Name Of Title Holder:
Vehicle ID (VIN):
Has This Motorcycle Been Modified?
If Yes To The Above Question, What Is The Value Of Modifications?	$
Is This A Custom Motorcycle?
If Yes To The Above Question, What Is The Appraised Value Of The Motorcycle?	$
This Motorcycle Is Driven To Work/School:	Miles
This Motorcycle Has An Alarm:
This Motorcycle Is Stored In:
If This Motorcycle Is Not Kept At The Above Adress, Please Provide The Information Below:
City: State: Zip:
Liability Limits - All Motorcycles Choose EITHER Bodily Injury & Property Damage OR Single Limit
Bodily Injury & Property Damage	Single Limit

Deductibles & Miscellaneous
Car #	Comprehensive Deductible	Collision Deductible	Towing	Loss Of Use
1
2
3

Driver #1 Information
Name	Relation	Date Of Birth	Sex
	Self
Marital Status	Courses Completed In The Last 3 Years

Driver #1 License Information
License Number:		State:	Years Licensed:
Driver #2 Information
Name	Relation	Date Of Birth	Sex

Marital Status	Courses Completed In The Last 3 Years

Driver #2 License Information
License Number:		State:	Years Licensed:
Driver #3 Information
Name	Relation	Date Of Birth	Sex

Marital Status	Courses Completed In The Last 3 Years

Driver #3 License Information
License Number:		State:	Years Licensed:
Driver #4 Information
Name	Relation	Date Of Birth	Sex

Marital Status	Courses Completed In The Last 3 Years

Driver #4 License Information
License Number:		State:	Years Licensed:

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




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

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.

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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