Company Information
Company name
*
DBA
Website URL
*
Phone Number
*
Please enter a valid phone number.
Company Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please provide information on your company's license below
Agency License Type
*
P&C
Surplus Lines
Other
Agency License State
*
All 50 States
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Agency 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
Agency 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
Ownership Structure
*
Sole Propriertorship
Corporation
Partnership
Other
Accounting Contact Name
*
First Name
Last Name
Accounting Contact Email
*
example@example.com
Accounting Contact Phone Number
*
Please enter a valid phone number.
Accounting Contact Information
*
Please provide the name, email and phone number of the accounting contact for your company
Business Plan/Company Overview (Optional)
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Producer/Agent Primary Contact Information
Please complete contact details for the person requesting appointment
Name
*
First Name
Last Name
Contact Job Title
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please provide information on your individual license below
Agent License Type
*
P&C
Surplus Lines
Other
Agent License State
*
All 50 States
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
Agent 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
I am a:
*
Retail Agent
Wholesale Broker
Interested in (select up to 3):
*
Bloodstock/Equine (Galileo)
Crisis Management
Commercial Auto
Concrete Pumping
Crane & Rigging
Cyber
Equipment Rental & Dealers
Fine Art
Flood
Heavy Transport
Inland Marine
Ocean Marine
Professional Liability
Transactional Risk
Political Violence
Surety
Tenant Legal Liability
Homeowners
Dwelling
Mobile Home
Residential Earthquake
Logistics
Workers Compensation (CA only)
Are you already in touch with a Territory Sales Manager for our Dwelling, Homeowners or Mobile Home offering?
*
Yes
No
Please list your Territory Sales Manager:
*
Interested in (select up to 3):
*
Builder's Risk
Crisis Management
Contractors/Construction
Commercial Auto
Concrete Pumping
Crane & Rigging
Cyber
Deductible Buyback
Earthquake
Energy Casualty
Environmental Liability
Equipment Rental & Dealers
E&S Property
Excess Liability
Fine Art
Flood
Heavy Transport
Inland Marine
Ocean Marine
Political Violence
Professional Liability
Transactional Risk
Tenant Legal Liability
Wind and All Perils
Worker's Compensation (CA only)
Salesforce Product Interest
Builder's Risk
Commercial Auto
Concrete Pumping
Contractors/Construction
Crane & Rigging
Crisis Management
Cyber
Deductible Buyback
Dwelling
E&S Property
Earthquake
Energy Casualty
Environmental Liability
Equipment Rental & Dealers
Excess Liability
Flood
Heavy Transport
Homeowners
Inland Marine
Logistics
Mobile Home
Ocean Marine
Political Violence
Professional Liability
Residential Earthquake
Surety
Tenant Legal Liability
Transactional Risk
Wind and All Perils
Worker's Compensation
Portfolio Information
Please describe your portfolio mix of business
Total Premium Volume $
*
Total Premium Volume $ - pre SF
*
Total Casualty Premium Volume $
Total Financial Premium Volume $
Total Commercial Premium Volume $
Total Personal Premium Volume $
Total Casualty Premium Volume $ - pre SF
Total Financial Premium Volume $ - pre SF
Total Commercial Premium Volume $ - pre SF
Total Personal Premium Volume $ - pre SF
If you selected Homeowners, Dwelling or Mobile Home above, do you have ACH documents to upload?
*
Yes
No
Please attach the following documents below:
Upload W9
*
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Agency License
*
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Individual License
*
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E&O Dec Page
*
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of
Upload ACH (required for Personal Property/NALICO products)
*
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Upload Background Authorization form (required for Property/NALICO products)
*
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Cyber Dec Page (Optional)
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Save
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