DUAL Become a Producer Form

Licensing Stage

Company name*

DBA

Website URL*

Phone Number*

Please enter a valid phone number.

Company Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

State*

Please select the Texas County for your address:*

Agency License Type*

P&CSurplus LinesOther

Other Detail:*

Agency License State*

Agency State Prefix

Salesforce Agency License States

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*

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

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

If you selected Crane & Rigging, Concrete Pumping, Equipment Rentals & Dealers, or Heavy Transport, please download and complete the documents below. You will be prompted to upload them at the end of this form.

Please attach the following documents below: