Cox Insurance Agency

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General Information
Your Name Last: First:
Business Name
Street Address1:
Street Address2:
City:    State:    Zip:
Daytime Phone: ( )   Fax: ( )
Evening Phone: ( ) 
Best Time To Call:   
Email Address:

Tell us about your business

Number of full-time employees

 Number of part-time employees
Number of locations
Estimated Annual Payroll$
Business Type:
Number years in business

Annual Receipts :
Limits of Liability needed :
Deductible
Property Coverages :   (building replacement cost)
Contents Coverages :

Physical Property Location
Please fill in this section if different than address above
Address

City

County

State

ZipCode
Description of Building 
Year Built

Construction Type

 

Foundation Type

 

Building Size
 (Square Footage First Floor)
Building Sprinklers

Yes
Swimming Pool

Yes
Heating & Air Conditioning Central AC  

Boiler Heat System
Number of Units
Number of Stories
Number of Buildings
Give Distance from:

Fire Hydrant (less than 1000 ft ?)

 Fire Station (less than 3 miles ?)

Please give age of the following :
Heating System Plumbing Electrical Roof

 

Current/Previous Insurance Information
Company Name
 (not an agency):
Policy Expiration Date:    Premium Amount: $
Losses or Claims in last 5 yrs.

number of claims

Details of any claims/losses from previous question:

Thank you for taking the time to complete this form.
We will contact you as soon as possible..
 
  
Please Notice: Cox Insurance Agency cannot bind, modify or cancel coverage via submissions to our website, or by messages sent through e-mail. Completion and submission of this form or e-mail does not constitute either a binder or an application for insurance. This site provides quotes and information only. An application signed by you and our agent is required for insurance to become effective.