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Cox Service Assurance Plan
Please provide the following information.
Date: mm/dd/yy  
First Name:
(on account)		  
Last Name:
(on account)		  
Address:  
City:  
State:  
Zip:   
Cox Account Number:  
   

I authorize Cox Communications to activate the Cox Assurance Plan on my account at a rate of $2.99 per month.

Electronic Signature:
(type first and last name)

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