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
DUALNALICOAlignCatalyticNBIS
Salesforce DUAL entity
DUAL entity calculation
YesNo
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
P&CSurplus LinesOther
All 50 StatesAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
State Prefix
All 50 StatesALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
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
Retail AgentWholesale Broker
I am a - calculation
Salesforce I am a
Artisan Contractors Pollution LiabilityBloodstock EquineCyberE&S HomeownersFlood (Commercial, Residential)Flood (Homeowner, Wright Flood)Inland MarineOcean MarineProfessional LiabilityTransactional RiskPolitical ViolenceSuretyHomeownersDwelling FireManufactured HomeWorkers Compensation
YesNo
Please list your Territory Sales Manager:*
Artisan Contractors Pollution LiabilityBloodstock EquineBuilder's RiskConstructionCyberDeductible BuybackEarthquakeEnergy CasualtyEnvironmental LiabilityE&S AutoE&S PropertyE&S HomeownersExcess LiabilityFlood (Commercial, Residential)Inland MarineOcean MarinePolitical ViolenceProfessional LiabilitySpecialty HealthcareSuretyTransactional RiskWindstorm RiskWorkers Compensation
Billing Type*
Surplus Lines Status*
Artisan Contractors Pollution LiabilityBloodstock EquineBuilder's RiskConstructionCyberDeductible BuybackDwelling FireE&S AutoE&S HomeownersE&S PropertyEarthquakeEnergy CasualtyEnvironmental LiabilityExcess LiabilityHomeownersInland MarineManufactured HomeOcean MarinePolitical ViolenceProfessional LiabilitySpecialty HealthcareSuretyTransactional RiskWindstorm RiskWorkers CompensationFlood (Homeowner, Wright Flood)Flood (Commercial, Residential)
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: