Pre Application

Complete the form below.

Please note that the "Proposed Insured" references to the person with the insurance policy will cover. The "Policy Owner" is responsible for the premiums and policy information. The "Beneficiary/Beneficiaries" will be the recipients of the death benefit associated with the policy.

First name*

Last name*

Your email*

Your phone number*

Type of Coverage Interested In:*

Term Life

Whole Life

Index Universal Life (IUL)

Usure (Would like guidance)

Name of the proposed Insured*

Proposed Insured DOB*

Proposed Insured SSN*

Purpose of Coverage:*

Family Protection

Mortgage Protection

Income Replacement

Final Expenses

Proposed Insured Height: *

Proposed Insured Weight:*

Does the Proposed Insured have a history of DUI or reckless driving in the past 5 years?

Yes

Does the Proposed Insured currently use tobacco or have you used it in the last 12 months? *

Yes

Proposed Insured's list of medications currently prescribed: (If none type "NA")*

Preposed Insured's pre-existing Medical Conditions (If none type "NA")

Havs the Proposed Insured been hospitalized or had surgery in the past 5 years? *

Yes

Does the Proposed Insured engage in any high-risk activities (e.g., skydiving, scuba diving, racing)?

Yes

Who will be the owner of this policy?

Beneficiary Information (Optional):*

Please select all that you have*

Recent pay stubs or income details.

Current life insurance and mortgage protection policies.

Retirement account statements (401k, IRA, pension)tion 2.

Mortgage, loan, and debt balances.

Bank statements (savings, checking, emergency fund)

State Issued ID/ Driver's License

Will you be prepared to pay your first premium with your checking/savings account and routing number?*

Yes, I have my checkng account and routing information

Yes, I have my savings account and routing information

No, I don't have a checkng or savings account and routing information

Here To Help You Plan For The Best & Be Prepared For The Unexpected

contact@skmfinancial.com

919-588-3977

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