Agency Partner Information

Date
Owners Name*
First Last
Owners Email*
Owners Phone*
Name of Agency*
Physical Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address if Different*
Street Address Address Line 2 City State ZIP Code
FEIN*
E & O Carrier*
E & O Limits
Per Accident
Per Claim/Occurance
E & O Effective Date*
Website*
States Licensed*
Annual Workers Compensation Written Premium*
Comments*
Please Include

Cimarron Insurance
7400 Carmel Executive Park Drive
Suite 320
Charlotte, NC 28226
Main 980-771-2490
info@cimarronins.com

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Cimarron is a focused group of insurance and risk management entities. We specialize in providing specialized and dedicated Workers Compensation solutions.

Date
Owners Name*
First Last
Owners Email*
Owners Phone*
Name of Agency*
Physical Address*
Street Address Address Line 2 City State ZIP Code
Is Your Mailing Address the Same as Your Physical Address?*
- Yes
- No
Mailing Address if Different*
Street Address Address Line 2 City State ZIP Code
Agency FEIN*
E & O Carrier*
E & O Limits
Per Accident
Per Claim/Occurance
E & O Effective Date*
Agency Website*
States Licensed*
Are You Appointed by McGowan Companies?*
- Yes
- No
Are You Appointed by Sole Pro to Offer Solo X Policies?*
- Yes
- No
Comments*
Agency Personnel
Agency Personnel
Please Include

Agency Partner Information

Agency Personnel