DUAL Individual Producers Form

Company Information
Company name*
Which one of our DUAL entities are you adding producers for?*

DUALNALICOOther
Do you need to add more than one producer?*

YesNo
Producer Code/Agency Code/PAC
DBA
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
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
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
I am a:*

Retail AgentWholesale Broker
Interested in (select up to 3):*

Bloodstock/Equine (Galileo)Crisis ManagementConcrete PumpingCrane & RiggingEquipment Rental & DealersE&S AutoHeavy TransportInland MarineOcean MarineCyberProfessional LiabilityTransactional RiskFine ArtFloodPolitical ViolenceTenant Legal LiabilityStandard Admitted AutoSuretyDwellingHomeownersMobile HomeResidential EarthquakeLogistics
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 CasualtyEquipment Rental & DealersE&S AutoE&S PropertyExcess LiabilityFine ArtFloodHeavy TransportInland MarineOcean MarinePolitical ViolenceProfessional LiabilitySpecialty HealthcareStandard Admitted AutoTransactional RiskWind and All PerilsWorker's Compensation
Please attach the following documents below:
Individual License*

Cancelof
Cyber Dec Page (Optional)

Cancelof
Should be Empty:

Company Information

Producer/Agent Primary Contact Information

Please provide information on your individual license below

Please attach the following documents below: