DUAL Additional Product Lines Form

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
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip 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
I am a:*

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

Bloodstock/Equine (Galileo)Crisis ManagementConcrete PumpingCrane & RiggingE&S AutoEquipment Rental & DealersHeavy TransportInland MarineOcean MarineCyberProfessional LiabilityTransactional RiskFine ArtFloodPolitical ViolenceTenant Legal LiabilityStandard Admitted AutoSuretyDwellingHomeownersMobile HomeResidential EarthquakeWorkers 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 CasualtyEquipment Rental & DealersE&S AutoE&S PropertyExcess LiabilityFine ArtFloodHeavy TransportInland MarineOcean MarinePolitical ViolenceProfessional LiabilitySpecialty HealthcareStandard Admitted AutoTransactional RiskWind and All PerilsWorker's Compensation (CA only)
Should be Empty:

Company Information

Producer/Agent Primary Contact Information