ProEquities Online Enrollment

 

Please complete all fields below to enroll online. This is a secure page and all data is fully encrypted.

Only payment in full by credit card is offered for online enrollment. To pay by check or commission deduction, please click here to download the enrollment form.

I agree

 
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Company Name
 
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First Name

 
 

Middle Initial

 
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Last Name

 
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Address 1

 
 

Address 2

 
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City

 
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State

 
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Zip Code

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Phone

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Fax

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Email

 

I understand and acknowledge I am not eligible for coverage under the ProEquities sponsored errors and omissions program unless I am legally contracted to represent ProEquities and its covered affiliates as of my coverage effective date. I understand if my contract to represent ProEquities or its covered affiliates is terminated, coverage under this program terminates on the same day and I am still responsible for the payment of the full annual rate. All payments are fully earned under this program and there will be no refund. I authorize Affinity Insurance Services, Inc. to process my enrollment. Your submission of this form and/or our preliminary acceptance of payment does not guarantee coverage. Should this submission be determined ineligible for coverage, your payment will be refunded.

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I agree

 

I have reviewed and understand the attached terms and conditions for the E&O program for ProEquities. I understand I will receive a certificate of coverage following my enrollment in this program. I will review this information and contact Affinity Insurances Services, Inc. with any questions.

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I agree

 
 
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Credit Card Type

 
Visa
Discover
Master Card
American Express
 
 
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Rates

None Found
 

*Rates include a Program Administration Fee and Affiliation Fee