ERMA Transfer Form

This form notifies ERMA that Cimarron included ERMA membership in a WC policy.

Date*
MM slash DD slash YYYY
Named Insured*
Named Insured
Insured Point of Contact*
First Last
Insured Email*
Insured Phone*
Policy & Membership Effective Date*
MM slash DD slash YYYY
Membership Fee Collected with Deposit?*
- This membership was REQUIRED as a condition of Cimarron Insurance Company agreeing to provide coverage. No schedule credit was applied.
- This membership was NOT REQUIRED as a condition of Cimarron Insurance Company agreeing to provide coverage. Schedule credits may have been applied.