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?*

DUALNALICOAlignCatalyticNBIS
Salesforce DUAL entity
DUAL entity calculation
Do you need to add more than one producer?*

YesNo
Producer/Agent Primary Contact Information

Please complete contact details for the person requesting appointment
Name*

First NameLast Name
Contact Job Title*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Street Address*
City*
State*
Postal Code*
If you are adding more than one producer, please list their full names, email addresses and phone numbers below. Please note that you will have the opportunity to upload multiple individual licenses below.
Please provide information on your individual license below
License Type*

P&CSurplus LinesOther
License State*

All 50 StatesAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
State Prefix
Salesforce API states

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
I am a:*

Retail AgentWholesale Broker
I am a - calculation
Salesforce I am a
Interested in (select up to 3):*

Artisan Contractors Pollution LiabilityBloodstock EquineCrisis ManagementCyberFlood (Commercial, Residential)Flood (Homeowner, Wright Flood)Inland MarineOcean MarineProfessional LiabilityTransactional RiskPolitical ViolenceSuretyHomeownersDwelling FireManufactured HomeLogisticsWorkers Compensation
Are you already in touch with a Territory Sales Manager for our Dwelling Fire, Homeowners, or Manufactured Home offering?*

YesNo
Please list your Territory Sales Manager:*
Interested in (select up to 3):*

Artisan Contractors Pollution LiabilityBloodstock EquineBuilder's RiskCrisis ManagementConstructionCyberDeductible BuybackEarthquakeEnergy CasualtyEnvironmental LiabilityE&S AutoE&S PropertyExcess CasualtyFlood (Commercial, Residential)LogisticsInland MarineOcean MarinePolitical ViolenceProfessional LiabilitySpecialty HealthcareSuretyTransactional RiskWindstorm RiskWorkers Compensation
Salesforce Product Interest*

Artisan Contractors Pollution LiabilityBloodstock EquineBuilder's RiskConstructionCrisis ManagementCyberDeductible BuybackDwelling FireE&S AutoE&S PropertyEarthquakeEnergy CasualtyEnvironmental LiabilityExcess CasualtyHomeownersInland MarineLogisticsManufactured 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 Primary Contact Information

Please provide information on your individual license below

Please attach the following documents below: