Mindy Siegel
RSRN Media Prod.
Independent FES Agent
(800) 998-1990
FES Protection Plan Enrollment Agreement
Please enter your enrollment information to the right. Missing or incorrect fields will be noted with a Red "X" and will not allow you to submit the form. Exclude any dashes within the Birthdate and SSN fields. Special characters such as commas will not be displayed. Any suffix (ie JR) should be placed in the Last Name field. Please double check your enrollment form to ensure accuracy before submission.
Missing or invalid payment information may delay application processing. Please verify that your payment information is correct before submission. Payments will be automatically processed upon clicking Submit. Please wait for your final confirmation page to ensure application process has completed. Print your confirmation page for your records.
Please read through the following documents. By clicking "I agree", you consent to the use of electronic records evidencing you have read through, understand and agree to all statements and Terms & Conditions of Enrollment. By submitting your online application, you are knowingly providing your electronic signature.
1. Enrollment Information
SSN  *
Birth Date  *
Title  *
Gender  *
First Name  *
Middle Initial    
Last Name  *
Address  *
Apt / Suite    
City  *
State  *
Zip Code  *
Email  *
Verify Email  *
Cell Phone  *
Alt. Phone    
2. Payment Information
Amount Paid  *
$188 (onetime setup fee $99 & Monthly Fee $89)
Payment Type  *
Card Type  *
Card Number  *
Exp Date  *
CVV Code  *
Routing Number  *
Account Number  *
Check #  *
Card First Name  *
Card Last Name  *
Billing Address  *
City  *
State  *
Zip Code  *
3. Terms & Conditions
Please Review and Check Off on the Following Terms:

Terms and Conditions of Enrollment.
Pref. language  *
Agent ID  *
Agent Name  *