Applicant’s Statements and Agreements:  1. I understand that the effective date of the policy will be the date recorded in the Policy Schedule of Benefits by the Company.  2. I understand the policy I am applying for contains different Waiting Periods for certain benefits listed in the Policy Schedule of Benefits. This means that no benefits are payable during the listed Waiting Period. The Waiting Period begins on the effective date of coverage.  3. I understand that dependent children, if any, will be covered until the end of the month following their 19th birthday (24th if full-time students).  4. I understand that: (a) Starmount Life Insurance Company is not bound by any statement made by me, the applicant, or any associate/agent of Starmount Life Insurance Company unless written herein. (b) The associate/agent cannot change the provisions of the policy or waive any of its provisions either orally or in writing. (c) The policy together with this application, endorsements, benefit agreements and riders, if any, is the entire contract of insurance. (d) No change to the policy will be valid until approved by Our president and secretary, and noted in or attached to the policy.

5. I acknowledge receipt of, if applicable:Outline of Coverage.

Authorization to Obtain Information: I authorize the following to give information (defined below) to Starmount Life Insurance Company or any person or group acting on their part: any medical professional, any medical care institution, insurer, reinsurer, government agency, or employer. “Information” means facts of a medical nature in regard to my physical or mental condition, employment, or other insurance coverage. I understand that this information will be used by Starmount Life Insurance Company to determine eligibility for insurance and may be used to evaluate a claim for benefits during the time it is valid. I agree that this authorization is valid for 30 months from the date signed. I know that I have a right to receive a copy of this authorization upon request. I agree that a copy of this authorization is as valid as the original.

Please Note : California law prohibits an HIV test from being required, DISCLOSED or used by health insurance companies as a condition of obtaining health insurance cove rage .

I understand that the premium amount listed on this application represents the premium amount that either my employer will remit to Starmount Life Insurance Company on my behalf, or I will remit directly to them. I further understand that this amount, because of my employer’s billing/payroll practices, may differ from the amount being deducted from my paycheck or the premium amount quoted to me by my associate/agent. I also understand that if I am receiving any Medicaid benefits, the purchase of this coverage may not be necessary. If I am applying to replace existing coverage with this policy, I acknowledge that the policies may have different benefits and that I should make a comparison to personally determine which is best for me. I understand and agree that I am terminating my current policy and its benefits for the benefits provided in the Starmount Life Insurance Company Policy. I have read, or had read to me, the completed application, and I realize policy issuance is based upon statements and answers provided herein, and they are complete and true to the best of my knowledge and belief. I understand that any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

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