Worker's Comp.

Cx Insurance Agency "We Insure Your World"

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:

Current/Previous Insurance Information

Company Name
(not an agency):

Policy Expiration Date: Premium Amount: $

Losses or Claims in last 5 yrs.
number of claims Total amount of claims $

Details of any claims/losses from previous question:

General Business Information

Number of full-time employees
Number of part-time employees

Number of locations Estimated Annual Payroll$

Business Type: Number years in business

Limits of Liability needed :

Briefly describe your business below, and types of work being performed by each employee:
(example - House Painting - int./ext., 1-office staff, 5 painters, 1 estimator)

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.