Starmount Life 1-888-SAY-LIFE  (1-888-729-5433)(855) 235-5999  
Starmount Life Insurance - Protect Tommorrow...by Planning Today!
StarLife Gold
Term Life Insurance.

Protection to age 95 - your cost will not change due to age or health.*
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StarLife Gold
Individual Life Application
Step One

 The application will take about 5 minutes to complete.
 4 screens are included.

First Name*
Last Name*
Date of Birth*
Email*
(e.g. you@somewhere.com)
Address*
City*
State*
Zip*
Sex*
Height*    Ft.     In. 
Weight*    (lbs.)
Home Phone*
(e.g. 555-555-5555)
Cell or Work Phone
(e.g. 555-555-5555)
Are you employed?*
Occupation / Duties
(Required if Employed. If disabled, explain.)
 
I wish to apply for insurance
in the amount of
*
Add Accidental Death Cash Option for*
Have you smoked, chewed, or used
tobacco in the last 24 months?
*
Do you smoke 2 or more packs per day?
(Required if Smoked in last 12 months)