DUAL Individual Producers Form

Current Date

MonthDayYear
Date
Effective Date

MonthDayYear
Date
Opportunity record type
Company Information
Company name
DBA
Producer Code/Agency Code/PAC
Which one of our DUAL entities are you adding producers for?
Salesforce DUAL entity
DUAL entity calculation
Do you need to add more than one producer?
Producer/Agent Contact Information

Please complete Contact details for each Producer/Agent
Name

First NameLast Name
Contact Job Title
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Street Address
City
State
Postal Code
Please provide information on your individual license below
License Type

Other
License State
State Prefix
Salesforce API states
Agent License Number
Note: DUAL uses the information you have provided to access your Agency/Producer licensing from NIPR. DUAL may perform these tasks itself or may use vendors with whom DUAL has contracted to perform this task. To view our Privacy Policy, please visit https://www.dualinsurance.com/dual-privacy-policy
National Producer Number (NPN)
Note: DUAL uses the information you have provided to access your Agency/Producer licensing from NIPR. DUAL may perform these tasks itself or may use vendors with whom DUAL has contracted to perform this task. To view our Privacy Policy, please visit https://www.dualinsurance.com/dual-privacy-policy
E&O Policy Carrier
E&O Policy Number
E&O Limit
E&O Expiration Date

MonthDayYear
Date
I am a:
I am a - calculation
Salesforce I am a
Interested in (select up to 5):
Are you already in touch with a Territory Sales Manager for our Dwelling Fire, Homeowners, or Manufactured Home offering?
Please list your Territory Sales Manager:
Interested in (select up to 5):
Billing Type
Surplus Lines Status
Salesforce Product Interest
Please attach the following documents below:
Agent License

Cancelof
Cyber Dec Page (Optional)

Cancelof
Agency License

Cancelof
E&O Dec Page

Cancelof
Sub-Appointment Documents

Cancelof
Agent License Type
Cyber Dec Page Type
Sub-appointment Type
E&O Dec Page Type
Agency License Doc Type
Opportunity Name
Should be Empty:

Company Information

Producer/Agent Contact Information

Please provide information on your individual license below

Please attach the following documents below: