DUAL Additional Product Lines Form

Current date

MonthDayYear
Date
Effective date

MonthDayYear
Date
Opportunity record type
Company Information
Agency/Company Name*
DBA
Producer/Agent Primary Contact Information

Please complete contact details for the person requesting appointment
Name*

First NameLast Name
Email*
example@example.com
Street Address*
City*
State*
Postal Code*
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 value
I am a - salesforce
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
Interested in (select up to 3):*

Artisan Contractors Pollution LiabilityBloodstock/EquineBuilder's RiskCrisis ManagementConstructionCyberDeductible BuybackEnergy CasualtyEnvironmental LiabilityE&S AutoE&S PropertyExcess CasualtyFlood (Commercial, Residential)LogisticsInland MarineOcean MarinePolitical ViolenceProfessional LiabilitySpecialty HealthcareSuretyTransactional RiskWindstorm RiskWorkers Compensation
Are you already in touch with a Territory Sales Manager for our Dwelling, Homeowners or Mobile Home offering?*

YesNo
Please list your Territory Sales Manager:*
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)
Opportunity Name
Should be Empty:

Company Information

Producer/Agent Primary Contact Information