Cox Insurance Agency

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General Information

Please Select from the following:
   
Business Name
Name: Last, First, MI. 
Address:
City:    State:    ZIP:
County:    Email:
Home Phone : ( )               
Work Phone :  ( ) 
Best time to call:    AM/PM

Tell us about your business
Briefly describe your business below, and types of work being performed by each employee:
(example - Computer Accounting Systems, 5-office staff, 3-field reps, 2 technicians)

Number full-time employees

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

Yearly Gross Income :
Limits of Liability needed :
Property Coverages : 
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:

Please include any additional information that we should be aware of when preparing the  insurance quote you have requested   

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.