(855) 235-5999
StarLife Gold
Term Life Insurance.
Protection to age 95 - your cost will not change due to age or health.*
Get a StarLife Gold Quote Now!
StarLife Gold Plan Apply Now!
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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
*
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
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8
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10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
Email
*
(e.g. you@somewhere.com)
Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
*
Sex
*
Male
Female
Height
*
--
0
1
2
3
4
5
6
7
8
Ft.
--
0
1
2
3
4
5
6
7
8
9
10
11
In.
Weight
*
(lbs.)
Home Phone
*
(e.g. 555-555-5555)
Cell or Work Phone
(e.g. 555-555-5555)
Are you employed?
*
Yes
No
Occupation / Duties
(Required if Employed. If disabled, explain.)
I wish to apply for insurance
in the amount of
*
Choose
Add Accidental Death Cash Option for
*
Double Benefits
Triple Beneftis
Not Interested
Have you smoked, chewed, or used
tobacco in the last
24
months?
*
Yes
No
Do you smoke 2 or more packs per day?
(Required if Smoked in last 12 months)
Yes
No