Cox Insurance Agency

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Part A : Tell Us Where To Contact You With Your Quote
 Name:
Last Name:
Address:
City: State:    Zip:
Day Phone: -  Evening Phone: -  
Fax: -   Email:
Best time to call: Time:  AM/PM

 

Part B : Select Coverage  and Length of Term Desired
  1. ${Can not exceed 60 percent of your gross annual income)
      

  2.   &

  3.   
  4. (Occupation - include all)

[Rates for disability insurance are partially determined by your occupation, If you have multiple occupations - please include them all in order for us to provide you with an accurate quote]

 

Part C: Personal Health

Any Physical Conditions: (Treated for or diagnosed)
1. Heart Condition Yes: No:
2. Cancer Yes: No:
3. Blood Pressure Yes: No:
4. Cholesterol Yes: No:
5. Bronchial Yes: No:
6. Kidney or Liver Yes: No:
7. Alcoholism Yes: No:
8. Drug Abuse Yes: No:
9. Diabetes Yes: No:
10. Other

 

Part D: Medications
Name Condition Treated
1.
2.

 

Part E : Tell Us About Your Health and Lifestyle 
 
Height: feet
 inches    
Weight: lbs
Date of Birth: Yr.
Gender :
Tobacco Usage:

Discontinued : If discontinued, when?
     

Hazardous Activities:
1. Pilot Yes: No:
2. Scuba Diving Yes: No:
3. Racing (vehicle or boat) Yes: No:
4. Rock Climbing Yes: No:
5. DUI or DWI in the past 10 years. Yes: No:

 

Part F: Family History: 
(Applies to Father, Mother, Sisters, Brothers)

Cardiovascular disease prior to age 60: Yes: No:
     Did condition result in death prior to age 60: Yes: No:
Cancer prior to age 60: Yes: No:
     Did condition result in death prior to age 60: Yes: No:

 
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Thank you for your time submitting this insurance quote form. One of our representatives will respond to you as quickly 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.