Please enable JavaScript in your browser to complete this form.Agent NameSelect AgentHeather TrentLori LeeJean SaxtonChristie NelsonDavid MartinezHeather FergusonReina NavarroSoila CastilloSarahi RuizSherri McElroyJena LawlessFortunato ArandaNick RobertsDawn RobertsSandra BivianNamePhone NumberEmailPreferred Language *EnglishSpanish.What is your preferred method of being contacted? (Select all that apply)EmailMailCallTextWhat Would You Like A Quote On? *--- Select Choice ---Auto InsuranceHome InsuranceRenter's InsuranceBusiness InsuranceCommercial Auto InsuranceRideshare InsuranceHealth InsurancePersonal Umbrella InsuranceOtherWould you like to share a few additional details so we can provide a more accurate quote? *YesNoWhen do you want coverage to start?How did you learn about our agency?--- Select Choice ---Web Search (Google, Bing, etc.)ReferralLeDoux WebsiteI'm an existing customerOtherListPlease select the office closest to you? *--- Select Choice ---Eugene, ORSalem, ORAlbany, ORWoodburn, ORDo you own or rent your home?OwnRentDo you own any recreational vehicles?YesNoList the recreational vehiclesWould you like to learn more about adding a Personal Umbrella policy for additional liability protection beyond your home and auto coverage?Yes, I’d like more informationNo, I decline this coverage Auto Insurance Garaging AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCurrent Policy InfoCurrent Company NameHow Long Have You Been With Current Carrier (Months/Years)?Upload Your Current Policy (For Comparison Of Coverages) Drag & Drop Files, Choose Files to Upload You can upload up to 3 files. Driver's InformationWhat Are Your Current Bodily Injury Liability Limits (EX: $100,000/$300,000)? - Skip If You Uploaded Your Current PolicyWhat Is Your Current Property Damange Liability Limit (EX: $100,000)? - Skip If You Uploaded Your Current PolicyWhat Is Your Current Annual Premium? If Policy Is For 6 Month Terms Please Confrim. - Skip If You Uploaded Your Current PolicyIf Second Policy Exists Please Upload Here or Fill Out This Form Using A Separate Link Drag & Drop Files, Choose Files to Upload You can upload up to 3 files. Driver 1 Driver 1 - NameFirstLastDriver 1 - License NumberDriver 1 - Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does Driver #1 Have A Defensive Drivers Course (if yes confirm date of completion)?Does Driver 1 Require SR-22?YesNoDriver 1 - Social Security NumberOptional. If you would like us to run an insurance score with your SSN, please check the box belowAuthorizationI authorize you to run the insurance score.Add another Driver?Yes Driver 2 Driver 2 - NameFirstLastDriver 2 - License NumberDriver 2 - Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does Driver 2 Have A Defensive Drivers Course (if yes confirm date of completion)?Does Driver 2 Require SR-22?YesNoDriver 2 - Social Security NumberOptional. If you would like us to run an insurance score with your SSN, please check the box belowAuthorizationI authorize you to run the insurance score.Add another Driver?Yes Driver 3 Driver 3 - NameFirstLastDriver 3 - License NumberDriver 3 - Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does Driver 3 Require SR-22?YesNoDriver 3 - Social Security NumberOptional. If you would like us to run an insurance score with your SSN, please check the box belowAuthorizationI authorize you to run the insurance score.Add another Driver?Yes Driver 4 Driver 4 - NameFirstLastDriver 4 - License NumberDriver 4 - Date of BirthDoes Driver 4 Require SR-22?YesNoDriver 4 - Social Security NumberOptional. If you would like us to run an insurance score with your SSN, please check the box belowAuthorizationI authorize you to run the insurance score.Add another Driver?Yes Driver 5 Driver 5 - NameFirstLastDriver 5 - License NumberDriver 5 - Date of BirthDoes Driver 5 Require SR-22?YesNoDriver 5 -Social Security NumberOptional. If you would like us to run an insurance score with your SSN, please check the box belowAuthorizationI authorize you to run the insurance score.Add another Driver?Yes Additional Drivers List additional drivers here:Upload Driver Licenses Drag & Drop Files, Choose Files to Upload You can upload up to 10 files. Upload Driver Defensive Drivers Certificates - Only If Applicable Drag & Drop Files, Choose Files to Upload You can upload up to 10 files. Are Any Of The Drivers Married? If Yes, Which Drivers?Do Any Of The Drivers Own A Home? If Yes, Which Drivers?Are There Other Licensed Drivers In The Household Not Listed Above?Vehicle Information Vehicle 1 Vehicle 1 - Confirm Vehicle Make/Model/Year - Skip If You Uploaded Your Current PolicyFirstMiddleLastVehicle 1- Confirm Vehicle Identification Number (VIN) - Skip If You Uploaded Your Current PolicyVehicle 1- Vehicle Mileage one-way to work(and/or commuting details)Vehicle 1- Is Vehicle Owned or Leased?Vehicle 1- Vehicle Purchase or Lease DateVehicle 1- Is This Vehicle Financed? If Yes, Who Is The Lienholder?Add another vehicle?Yes Vehicle 2 Vehicle 2 - Confirm Vehicle Make/Model/Year - Skip If You Uploaded Your Current PolicyFirstMiddleLastVehicle 2 - Confirm Vehicle Identification Number (VIN) - Skip If You Uploaded Your Current PolicyVehicle 2 - Vehicle Mileage one-way to work(and/or commuting details)Vehicle 2 - Is Vehicle Owned or Leased?Vehicle 2 - Vehicle Purchase or Lease DateVehicle 2 - Is This Vehicle Financed? If Yes, Who Is The Lienholder?Add another vehicle?Yes Vehicle 3 Vehicle 3 - Confirm Vehicle Make/Model/Year - Skip If You Uploaded Your Current PolicyFirstMiddleLastVehicle 3 - Confirm Vehicle Identification Number (VIN) - Skip If You Uploaded Your Current PolicyVehicle 3 - Vehicle Mileage one-way to work(and/or commuting details)Vehicle 3 - Is Vehicle Owned or Leased?Vehicle 3 - Vehicle Purchase or Lease DateVehicle 3 - Is This Vehicle Financed? If Yes, Who Is The Lienholder?Add another vehicle?Yes Vehicle 4 Vehicle 4 - Confirm Vehicle Make/Model/Year - Skip If You Uploaded Your Current PolicyFirstMiddleLastVehicle 4 - Confirm Vehicle Identification Number (VIN) - Skip If You Uploaded Your Current PolicyVehicle 4 - Vehicle Mileage one-way to work(and/or commuting details)Vehicle 4 - Is Vehicle Owned or Leased?Vehicle 4 - Vehicle Purchase or Lease DateVehicle 4 - Is This Vehicle Financed? If Yes, Who Is The Lienholder?Add another vehicle?Yes Vehicle 5 Vehicle 5 - Confirm Vehicle Make/Model/Year - Skip If You Uploaded Your Current PolicyFirstMiddleLastVehicle 5 - Confirm Vehicle Identification Number (VIN) - Skip If You Uploaded Your Current PolicyVehicle 5 - Vehicle Mileage one-way to work(and/or commuting details)Vehicle 5 - Is Vehicle Owned or Leased?Vehicle 5 - Vehicle Purchase or Lease DateVehicle 5 - Is This Vehicle Financed? If Yes, Who Is The Lienholder?Add another vehicle?Yes Additional Vehicles List any additional vehicles here:Add another vehicle?YesClaim InfoDo you, your spouse, and/or any other drivers listed have any driving, claims tickets or accidents within the past 5 years? If yes, please confirm: Description of claim, Date or approx. date of claim, Amount of Claim/loss, Claim open or closed, At fault if not at fault (auto). (Kindly note we will run Motor Vehicle Reports as well. [Please note a standard Motor Vehicle Report will be processed]). Home Insurance Insured's Contact InformationPlease answer for all insured persons. Person 1 Person 1 - NamePerson 1 - Date Of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Person 1 - Cell PhonePerson 1 - Email AddressPerson 1 - SSN (optional but good credit may help rate)Person 1 - Education/Occupation/Employer/Years With Current EmployerPerson 1 - Previous Living Address If Less Than 3 YearsAdd another person?Yes Person 2 Person 2 - NamePerson 2- Date Of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Person 2 - Cell PhonePerson 2 - Email AddressPerson 2 - SSN (optional but good credit may help rate)Person 2 - Education/Occupation/Employer/Years With Current EmployerPerson 2 - Previous Living Address If Less Than 3 YearsAdd another person?Yes Person 3 Person 3 - NamePerson 3- Date Of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Person 3 - Cell PhonePerson 3 - Email AddressPerson 3 - SSN (optional but good credit may help rate)Person 3 - Education/Occupation/Employer/Years With Current EmployerPerson 3 - Previous Living Address If Less Than 3 YearsAdd another person?Yes Person 4 Person 4 - NamePerson 4- Date Of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Person 4 - Cell PhonePerson 4 - Email AddressPerson 4 - SSN (optional but good credit may help rate)Person 4 - Education/Occupation/Employer/Years With Current EmployerPerson 4 - Previous Living Address If Less Than 3 YearsAdd another person?Yes Person 5 Person 5 - NamePerson 5 - Date Of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Person 5 - Cell PhonePerson 5 - Email AddressPerson 5 - SSN (optional but good credit may help rate)Person 5 - Education/Occupation/Employer/Years With Current EmployerPerson 5 - Previous Living Address If Less Than 3 YearsAdd another person?Yes Additional Persons List additional people here:Home Details & InformationPlease answer the following to the best of your knowledge. Any unknown answers please leave blank or supply at a later date/time. Some details maybe eligible for discounts so we like to collect as much as we can!If You Are Currently Insured, Who Is The Insurance Carrier & What Date (DD/MM/YYYY) Does it Expire?If You Have A Current Homeowners Insurance Policy - Please Upload It Here For Helpful Comparison Drag & Drop Files, Choose Files to Upload Property AddressAddress Of The Home To Be InsuredAddress Line 1Address Line 2CityState / Province / RegionAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIs this is a new purchase?YesNoWhat is your current address?Address Line 1Address Line 2CityState / Province / RegionAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHow long have you lived at the current address?Estimated Closing DateEstimated Move In DateWill The Home Be Vacant and/or Under Significant RenovationsYesNoPlease Provide Specific Details Including Length Of Vacancy and/or Renovations:Loan #, Lender's Name, Lender's Address, and Lender's Phone Number Of Your Mortgage Lender (IF APPLICABLE)Have there been any claims against your current or previous insurance companies in the last 5 years? If yes, please describe what happened, payment amount, closing date of claim(s).Usage TypePrimary HomeSecondary HomeOccupancyOwnedRentedNumber Of FamiliesSingle FamilyTwo FamilyThree FamilyFour FamilyType Of StructureDwellingApartmentCondoTownhouseCo-OpHome Structure Material (majority)Wood FrameBrick FrameSteel FrameConcrete FrameJoisted or Load Bearing MasonryStyle Of Home StructureCap CodColonialRanchSplit Level RanchContemporaryCottageCraftsmanGreek RevivalFarmhouseFrench CountryMediterraneanMid-Century ModernSplit-LevelTudorVictorianOther if (APT, Condo, Townhouse, CO OP)I am not sure!Type Of RoofGableHipDutchMansardFlatShedGambrelOtherI am not sure!Year BuiltSquare FeetNumber of StoriesNumber Of BedroomsNumber Of Bathrooms (Full, Half)Number Of KitchensIs there a basement? If yes, is it finished, partially finished or unfinished? What % of the home does it cover (estimated)? Does it get daylight?Is there a garage? If yes, is it attached or detached and how many cars does it hold?What type of heat does the home provide? If oil, where is the tank located (above ground, below ground, basement)?Electrical System (Circuit Breaker, Fuses)Wiring (Copper, Aluminum, Knob & Tube)Is there a fire place? If yes, what type - chimney, pre-fab, wood stove?Do you have a swimming pool? If yes, is it above ground or below ground? Is there a fence? Is there a slide or diving board?Do You Have A Dog? If Yes, Confirm Breed and Is There Any Bite History?Is there a back deck?Is there a front porch? If yes, screened in or open?Is the building undergoing renovation or construction?NoYesIs the property within 300-feet of a commercial or non-residential property? If yes, what type of property?NoYesAre there solar panels?NoYesHave there been any updates to the following: Heat, Electrical, Roof and/or Plumbing in past 10 years? If so please describe what year for each, and brief details of the updates:Discount QuestionsThe following questions may assist in additional discounts availableDo you have a burglar alarm? If yes, is it local (in home only), or central (leading to emergency service)?Do you have a fire alarm? If yes, is it local (in home only), or central (leading to emergency service)?Do you have an internal sprinkler system (rare, but additional discounts apply)?Additional Information, Questions, or RequestsPlease submit any questions or additional information that may be relevantOpt-InBy submitting this form and signing up for texts, I agree to receive conversational text messages from LeDoux Insurance using the contact information provided. For help, reply HELP. Opt out of receiving text messages at any time by sending STOP. Message and data rates may apply. Message frequency varies. Please view our Privacy PolicySubmit
