Client Application - Keystar Insurance

First Name *

Middle Initial

Last Name *

Suffix

Address *

Address

City

State/Province

Zip/Postal

Birthday *

Email *

Phone *

Gender *

Male

Female

This is sex assigned at birth.

Do you currently smoke? *

Yes

No

This includes the use of tobacco/nicotine products, such as cigarettes, cigars, cigarillos, a pipe, chewing tobacco, or nicotine delivery devices such as nicotine patches or nicotine gum? This also includes the use of marijuana in all forms.

Do you have any conditions which are treated with prescription medication? *

Yes

No

This includes ailments being treated by a medical professional. This will not prevent you from qualifying for coverage.

Household Income

Monthly Budget

This helps us know what kind of policies may fit into your budget.

Type of Insurance *

This will let us know what type of policy your are interested in.

Length Of Coverage *

The amount of time you want the policy to protect you.

Coverage Amount *