Agent System Access Form

Employee: First MI Last
Agency Name: Agency Code:
National Producer Number: Email:
Business Phone: Ext.

Role

Agency Principal
Producer
Manager - Personal
CSR - Personal
Manager - Commercial
CSR - Commercial
Supervisor - Personal
Supervisor - Commercial
Accounting/Finance

Licensing and Access

License Number Copy of License State Full System Access
Policy Inquiry Access
CT
MA
RI
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Requested by Principal/Designee: Date:
If you have any questions, please contact the NLC Help Desk at (800)-962-0800 ext. 4226