LIFE INSURANCE NEEDS ASSESSMENT

Do NOT include your SIN or any sensitive account numbers.
Please fill out the form below so we can assess your insurance needs accurately.

Full Name *

Date of birth *

Email *

Mobile Number *

City and Province *

Preferred Languange *

English

Français

Both / Either

Smoking Status:

Non-smoker

Smoker

Quit smoking (more than 12 months ago)

Any major health concerns we should know about?

Do you have children under 16? *

Yes

If YES, please list their name(s) and age(s):

Biweekly Net Income *

Do you have a mortgage? *

Yes

If YES, mortgage balance:

Other debts (select all that apply): *

Credit card debt

Personal loan

Car loan

Line of credit

Student loan

No other debts

If you selected any debts, please estimate the total debt amount:

Do you currently have life insurance? *

Yes

Not sure

If YES, please list the company and coverage amount:

What is your immigration status? *

Canadian Citizen

Permanent Resident

Open Work Permit

Closed Work Permit

Student Visa

Visitor

Refugee / PR Pending

Other

How would you prefer to meet? *

Online (Zoom / video call)

In person (if available in my area)

Consent to be contacted
I agree that a representative from JK Infinite Solutions may contact me by phone, email, or text message to discuss my financial needs and potential solutions.

CASL / marketing consent
I would like to receive educational content, invitations to webinars, and updates about financial strategies and services. I understand I can unsubscribe at any time.

This form is for assessment purposes only and does not constitute a quote or approval. Please do not enter any SIN or sensitive information. All life insurance recommendations depend on proper underwriting, licensing rules per province, and carrier eligibility.