Step 1: Agent Information

Enter your full legal information exactly as it should appear on your agreement.

First name *

Last name (full legal) *

Email *

Mobile phone *

NPN (numbers only, up to 10 digits) *

Resident state *

Licensed states *

Hold Ctrl/Cmd to select multiple states.

Agency name

Agency principal/upline name

EnrollHere agent ID or login email *

Used to match your lead activity to your account.

Step 2: Billing Information

Billing name *

Street *

City *

State *

ZIP *

Step 3: Program Fees

Review the program charges before continuing.

Lead Program Deposit$1,000

Refundable security deposit held first 90 daysRefundable

Agent Setup Fee$99 one-time non-refundable

Dialer & System Access Fee$200/mo

Leads$22/lead

45 leads delivered$990 billed each time

Due today$1,299

Due today is deposit + setup + first month.

Step 4: Payment Method

QuickBooks Payments

Secure payment fields powered by QuickBooks Payments (ACH preferred). Live QBO Payments connection coming next — do not enter real card data here yet.

Choose your preference. Live hosted fields will replace this placeholder once QBO is connected.

ACH Preferred Card

Payment method will be saved for authorized off-session charges. No raw card or bank numbers are collected on this page.

Step 5: Authorizations

Each authorization is required to enroll.

1. "I authorize America's Trusted Benefits LLC to charge my payment method $200 per month for dialer and system access until I cancel in writing."2. "I authorize America's Trusted Benefits LLC to charge my payment method $990 each time 45 leads are delivered to my account."3. "I understand that if any charge is declined, lead delivery stops immediately and my $1,000 deposit may be applied to or forfeited against my outstanding balance."4. "I have read and agree to the Dialer and Lead Program Terms."

Dialer and Lead Program Terms — version 1.0

Lead Program Deposit. Agent provides a $1,000 refundable security deposit held for the first 90 days. It may be applied to unpaid amounts; any remaining balance is refundable after 90 days subject to review and no outstanding balance.

Lead Billing. Leads are billed at $22 per lead. $990 is due each time 45 leads are delivered to the EnrollHere account associated with Agent.

Non-Payment. If any charge is declined, overdue, reversed, or unpaid, lead delivery stops immediately. ATB may apply or forfeit the deposit against the outstanding balance and suspend dialer/system access until current.

Dialer and System Access Fee. Agent authorizes a recurring $200 monthly fee for dialer and system access until canceled in writing; it excludes lead charges and the setup fee.

Agent Setup Fee. The $99 setup fee is one-time and non-refundable for onboarding, configuration, and access setup.

Program Participation. Agent confirms accurate information, required licenses, and lawful use of dialer, systems, and leads under applicable rules and EnrollHere requirements. Version 1.0 may be updated prospectively in writing; cancellation does not remove amounts already incurred.

PDF download: coming soon.

Step 6: Electronic Signature

Type your full legal name exactly as entered in Step 1.

Typed full legal name *

I agree that typing my name above is my electronic signature.

Date/time ET, IP, browser, and terms version 1.0 will be recorded on submit.

Thank you — enrollment received

Your Agent Portal enrollment has been recorded for review.

Charged today$1,299

Ongoing dialer & system access$200/month

Lead billing$990 per 45 leads delivered

An agent will be emailed the signed terms. Admin [email protected] notified with no payment details.

QuickBooks Payments is not connected yet; the payment step was a secure placeholder. Live hosted ACH/card fields will be added before real payment collection.