1. My annual commission and fee revenue are less than $499,999 (New agents should estimate annual commissions and fees.). 
  2. I am an independent life agent.
  3. More than 50% of my revenue is derived from sales of Life, Accident, Health, Disability, Long Term Care and Annuity Products.
  4. I do not perform any services as a registered investment advisor or have an ownership interest in a broker dealer.
  5. I do not have any discretionary authority relating to the funds of others for a fee.
  6. I have not received any professional liablity errors and omissions complaints, filed any errors and omissions claims with an insurance carrier or been involved in any arbitration, civil or criminal legal proceedings within the past 3 years.
  7. I have not been the subject of any professional liability disciplinary action, or a defendant or respondent to any complaint or allegation that resulted in any type of adverse action by any state, federal , or regulatory agency within the past 3 years.
  8. I do not have any knowledge or information of any fact, situation, allegation, complaint or incident which might result in a complaint, claim, suit or arbitration proceeding against me or my errors and omissions insurance.

Based on the statements above, please select the appropriate response below.


Basic (Life, Accident & Health, Long Term Care, Disability, Medicare Advantage and Medicare Supplements) Deductible: $1,000 each claim.

Agents' Errors and Omissions Plan

Complete the enrollment form below and click submit. If you submit the form online, we request that you pay, in full, with a credit card.

Please note that this enrollment form is on a secure page and all data is encrypted.

* Required

Please enroll me in the Errors and Omissions (E&O) Program. I have indicated my credit card authorization for coverage for the policy period. In lieu of a signature, I am providing my credit card authorization to represent my acceptance of all terms and conditions of this policy.


I agree


First Name


Middle Initial


Last Name


Address 1


Address 2






Zip Code



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Please enter a date or select full prior acts if appropriate.

Full Prior Acts
Retro Date


I authorize Affinity Insurance Services, Inc. to process my enrollment. I understand and acknowledge that submission of this form and/or our preliminary acceptance of payment does not guarantee coverage. Should this submission be determined to be ineligible for coverage, your premium will be refunded.


I agree


I have reviewed and understand the attached terms and conditions for the E&O program. 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.


I agree


Credit Card Type

Master Card
American Express

Effective Date


Expiration Date




Includes a $40 purchasing group fee in the Agents Professional Liability Service Organization.

Premium also includes a surplus lines tax. To view the tax amounts please view the Surplus Lines Chart.

Other payment options:

If you prefer to pay by check, please follow these instructions:

Download and print the Enrollment Form for Agent Solutions
Make your check payable to Affinity Insurance Services, Inc.
Complete the Enrollment form and mail it with your check to:

PO Box 392071
Pittsburgh, PA 15251-9071

Overnight Mailing:
Affinity/Agents Division
Attn: Lockbox 392071
500 Ross Street 154-0455
Pittsburgh, PA 15262-0001