IN Platinum Member Enrollment

* indicates a required field.

Account Info

Email * Your email will be used as your username

Confirm Email *

Use Email as Username

Username *

Choose Password *

Confirm Password *

What type of Membership is this?

Corporate

Individual

First Name *

Middle Name

Last Name *

Desk/Home Phone

Phone *

Your Direct Selling Company *

Company ID Number (Consultant, Representative, Distributor)

Date of Birth *

Business Name

Mailing Address

Address Line 1 *

Address Line 2 mailing_street2_validation

City *

State *

Zip Code*

Billing Address

Same as Mailing Address

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Agree with Terms and Conditions *

Terms and Conditions

Definition of Named Insured for Direct Seller Liability Coverage: Sports, Leisure and Entertainment Risk Purchasing Group and its enrolled member direct selling independent contractors whose names are on file with the company and for which an appropriate premium has been paid and to whom a certificate of insurance has been issued.

Definition of Named Insured for Business Inventory Coverage: Those enrolled member direct selling independent contractors whose name is on file with the company and for which an appropriate premium has been paid and to whom an evidence of property document has been issued.

Completion of this enrollment form confirms your desire to obtain insurance through the Sports, Leisure and Entertainment Risk Purchasing Group or the WellnessPROPurchasing Group. The submission of this enrollment form and/or acceptance of payment does not guarantee coverage. Certain operations are not eligible for coverage under this program. PRO Insurance Managers reserves the right to decline any request for coverage. Upon receipt of a completed application, if it is determined that an applicant is not eligible for coverage your premium for the policy will be refunded. You realize that any false, or inaccurate statement or misrepresentation in the enrollment form may result in claim denial or contract rescission. Any person who injures, defrauds, or deceives any insurer, files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. You understand that the plan applied for will not pay benefits for any expenses incurred on account of any claim before the effective date or for the products/services that you sell/market. You further acknowledge that you have reviewed all information provided with this enrollment form and understand the exclusions that apply, as well as the activities and operations for which coverage is not provided.

Accepted Payment Method/Terms: Payments are due in full payable by credit card at time of enrollment. I understand the plan hereby applied for will not be considered inforce until a policy or certificate is issued and full payment of applicable charges andfees has been received and other conditions remain as described in this application. Any charges and fees charged under this program are fully earned and are not refundable. No representation except by PRO Insurance Managers, Inc. or the company are binding. No other person has the authority to issue or change coverage or the effective date of coverage.

Warranty & Electronic Disclosure and ConsentElectronic Signature Disclosure and ConsentThe Electronic Signatures in Global and National Commerce Act (15 U.S.C. subsection7001, et seq.) provides that a signature, contract or other record may not be denied legal effect, validity or enforceability solely because it is in electronic form or because an electronic signature was used in a transaction. PRO lnsurance Managers, Inc. (PRO), whether on its own behalf and/or on behalf of an insurer and/or third parties, may utilize the internet, email, cloud services, digital storage, digital media or similar electronic means to transmit Policy Documents to its clients. This Agreement informs you of your rights when we are delivering and you arereceiving such documents from us electronically. To Report a Claim: If you have a loss and need to report a claim, please call us at 1-800-821-7383 (Monday – Thursday 8-6 ET and Friday 9-5 ET), from anywhere in the country.

By agreeing to proceed with this transaction, you acknowledge and consent to the following:1. I hereby voluntarily consent to proceeding with this transaction, and all subsequent actions related to this transaction, electronically.

2. I understand that further documents relating to this insurance purchased through PRO, including but not limited to correspondence, communications, confirmations, requests for premium payments and policy documents, may, to the extent permitted by law, be transmitted by electronic means to me, including by e-mail sent to the e-mail address I have provided as part of this transaction and/or my on-line registration. I consent to such documents being provided to me electronically.

3. Notwithstanding paragraph 2, any notice of cancellation shall be sent to me by mailing to the address I have provided as part of my registration and/or application for insurance, or to such other address for which I have provided notice pursuant to the terms of the policy.

4. Any change or revision to the e-mail address or other electronic contact information which I have provided as part of this transaction and/or my on-line registration process hall be requested by me by logging onto this website, or by mailing a written notice to: PRO lnsurance Managers, Inc. Powered by Gallagher Affinity 8430 Enterprise Cir. Suite200 Lakewood Ranch, FL 34202

5. I understand that I have the right to obtain a paper copy of any electronic record provided to me pursuant to this transaction or any subsequent transaction involving my coverage by mailing a written request to the address provided in paragraph 4.

6. ln order to access the electronic records provided, the following hardware and software are required: (a) a personal computer or other device through which internet access is available, (b) an internet connection, (c)an e-mail account with an internet service provider, and (d) Adobe Acrobat Reader.

7. I understand that I have the right and option to withdraw my consent to the receipt of further electronic documents at any time, by mailing a written request to the address provided in paragraph 4. By withdrawing my consent to electronic delivery of documents I understand that I will receive a paper copy of future policy documentation. 8. lnformation relating to this transaction is subject to the terms of our privacy statement, a copy of which is provided at www.pro4.us.

9. Gallagher’s liability to Client arising from any acts or omissions of Gallagher shall not exceed $20 million in the aggregate. Gallagher shall only be liable for actual damages incurred by Client, and shall not be liable for any indirect, consequential or punitive

I have a voucher

I don't have a voucher

Voucher Number *

I will pay my membership:

Annual Monthly