DUAL Become a Producer Form

Licensing Stage
Company Information
Company name*
DBA
Website URL*
Phone Number*
Please enter a valid phone number.
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State*
Please select the Texas County for your address:*
Please provide information on your company's license below
Agency License Type*

P&CSurplus LinesOther
Other Detail:*
Agency License State*

All 50 StatesAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Agency State Prefix
Salesforce Agency License States

All 50 StatesALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
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 ProprietorshipCorporationPartnershipSingle-Member LLCOther
Other Detail:*
Accounting Contact Name*

First NameLast 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)

Help us understand your business
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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.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State*
Address State Prefix
Salesforce Agent State
Please provide information on your individual license below
Agent License Type*

P&CSurplus LinesOther
Other Detail:*
Agent License State*

All 50 StatesAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Agent State Prefix
Salesforce Agent License States

All 50 StatesALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
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 AgentWholesale Broker
I am a: Calculated Field Value
Salesforce Agent Type
Interested in (select up to 3):*

Bloodstock/Equine (Galileo)Crisis ManagementConcrete PumpingCrane & RiggingCyberEquipment Rental & DealersFine ArtFloodHeavy TransportInland MarineOcean MarineProfessional LiabilityTransactional RiskPolitical ViolenceStandard Admitted AutoSuretyTenant Legal LiabilityHomeownersDwellingMobile HomeResidential EarthquakeLogisticsWorkers Compensation (CA only)
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:*
Interested in (select up to 3):*

Builder's RiskCrisis ManagementContractors/ConstructionConcrete PumpingCrane & RiggingCyberDeductible BuybackEarthquakeEnergy CasualtyEnvironmental LiabilityEquipment Rental & DealersE&S AutoE&S PropertyExcess LiabilityFine ArtFloodHeavy TransportInland MarineOcean MarinePolitical ViolenceProfessional LiabilitySpecialty HealthcareStandard Admitted AutoTransactional RiskTenant Legal LiabilityWind and All PerilsWorker's Compensation (CA only)
Are you already in touch with an E&S Auto/Standard Admitted Auto Underwriter or divison leader?*

YesNo
Please list the Underwriter you've been in touch with:*
Salesforce Product Interest

Builder's RiskConcrete PumpingContractors/ConstructionCrane & RiggingCrisis ManagementCyberDeductible BuybackDwellingE&S AutoE&S PropertyEarthquakeEnergy CasualtyEnvironmental LiabilityEquipment Rental & DealersExcess LiabilityFloodHeavy TransportHomeownersInland MarineLogisticsMobile HomeOcean MarinePolitical ViolenceProfessional LiabilityResidential EarthquakeStandard Admitted AutoSuretyTenant Legal LiabilityTransactional RiskWind and All PerilsWorker'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?*

YesNo
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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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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Should be Empty:

Company Information

Please provide information on your company's license below

Producer/Agent Primary Contact Information

Please provide information on your individual license below

Portfolio Information

Please attach the following documents below: