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
Attach File
CT
Attach File
MA
Attach File
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
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