HEALTH & DENTAL PLANS

Do NOT include SIN or any sensitive account numbers.
Please fill out the form below so we can assess your eligibility and recommend the right Health & Dental plan for your family.

Full Name *

Date of Birth *

Email *

Mobile Number *

City & Province of Residence *

Preferred Languange *

English

Français

Both / Either

Do you have a spouse or partner to include on the plan? *

Yes

Do you have children or dependents to include? *

Yes

If YES, list each child below:

Example format: Child 1: Name, Date of Birth (YYYY-MM-DD) Child 2: Name, Date of Birth (YYYY-MM-DD) Child 3: Name, Date of Birth (YYYY-MM-DD)

Employment Status *

Employee

Self-employed

Contractor

Business owner

Other

Do you currently have any Health & Dental benefits through work? *

Yes

I'm not sure

If YES, are you looking to:

Replace current coverage

Add supplementary coverage

Compare prices

Add family members

Not sure yet

What coverage types are you most interested in? (Choose all that apply)

Prescription drugs

Dental (basic & major)

Vision care

Paramedical services (massage, physio, chiro, etc.)

Travel medical insurance

Hospital benefits

Mental health services

Emergency medical coverage

Not sure — need guidance

Do any family members have ongoing medical conditions, medications, or upcoming treatments?

Yes

Prefer not to say

If YES, please describe (optional).

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 only and does not guarantee approval. All coverage is subject to underwriting rules, carrier eligibility, and provincial regulations. Do not include SIN or sensitive information.