Online Application

(855) 235-5999

StarLife Gold
Term Life Insurance.
Protection to age 95 - your cost will not change due to age or health.*

StarLife Gold
Individual Life Application

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*	MaleFemale
Height*	Ft. In.
Weight*	(lbs.)
Home Phone*	(e.g. 555-555-5555)
Cell or Work Phone	(e.g. 555-555-5555)
Are you employed?*	YesNo
Occupation / Duties (Required if Employed. If disabled, explain.)
I wish to apply for insurance in the amount of*
Add Accidental Death Cash Option for*	Double BenefitsTriple BeneftisNot Interested
Have you smoked, chewed, or used tobacco in the last 24 months?*	YesNo
Do you smoke 2 or more packs per day? (Required if Smoked in last 12 months)	YesNo