Cox Insurance Agency

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General Information

Please Select from the following:
   
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

 Business Type: 

Number of part-time employees
Estimated Annual Payroll$
Number years in business
Yearly Gross Sales :
Number of locations

Limits of Liability needed :
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.