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Title: Mr.Ms.* Name: * Email: * (e.g. you@somewhere.com) Address: * City: * State: -- AK AL AR AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY * Zip: * Home Phone: (e.g. 555-555-5555) Work or Cell Phone: (e.g. 555-555-5555) Your date of birth is: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 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 * Have you ever owned an InsuranceLife.com, Starmount Life, or Health Insurance Policy? YesNo Do you currently own an InsuranceLife.com, Starmount Life or Health Insurance Policy? YesNo Please Choose One:* I want information on the ValueLife Gold policy (has 1 rate change at the beginning of year 6; another at year 11; then no further changes). You will have many opportunities to change to a level cost policy. I want information on the StarLife Gold policy (a level cost term policy to age 95). Your cost will never increase because of your age or health. Only if everyone in your classification has a rate change will you have one. You cannot be singled out. Just put me on your mailing list. How did you find InsuranceLife.com? Pick an Option A friend A Starmount Mailing or Brochure Found on the Internet Ad Banner A Newsletter Other By providing your email address, you will periodically receive emails regarding new products and special offers. Of course, you may unsubscribe at any time.