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Get Your Exact Rate

Thank you.

I will personally review your answers and reach out within 24 hours with real carrier options. No obligation.

Get Your Exact Rate

Want Your Real Rate — Not Just an Estimate?

Answer a few questions about your health and HIV status, and I will personally shop the carriers that actually approve HIV-positive applicants, then call or email you within 24 hours with real numbers, not a ballpark.

1Your Contact Info

First Name *

Last Name *

Email *

Phone *

State *

Gender *

Female Male

Date of Birth *

Citizenship *

US citizen Green card holder Visa holder Other

Visa type (if any)

Years in the US

Country of citizenship

2Coverage You’re Looking For

What type of life insurance? *

Term life Permanent (whole or universal life) Final expense Not sure, help me choose

For how many years?

10 years 15 years 20 years 30 years Not sure

Coverage Amount

$250,000

Annual income

Occupation

Do you have any life insurance now? *

Yes No

About how much? Would the new policy replace it?

Yes No Not sure

3Your HIV & Health Profile

Your answers stay private. They help me match you with the carriers that actually approve people living with HIV.

Height *

Weight (lbs) *

How long ago were you diagnosed with HIV? *

Do you know if you have HIV-1 or HIV-2? *

Are you currently taking antiretroviral therapy (ART)? *

Yes No

How long have you been on your current regimen without changes? *

Has your doctor recommended starting treatment, or do you have plans to start soon?

Yes No

Has your CD4 count stayed above 500 for at least the past year?

Yes No Not sure

What HIV medication(s) are you currently taking?

Have you had an AIDS-defining illness or opportunistic infection in the past 5 years, or since starting your current treatment? *

Yes No

Which one? (select all that apply)

PCP pneumonia Kaposi sarcoma Cryptococcal meningitis Wasting syndrome Not sure / other

What is your most recent CD4 count? *

Below 200 200-349 350-499 500 or above Not sure

Has your CD4 count ever dropped below 200, including at diagnosis? *

Yes No Not sure

About how many years ago was that? How long have you been on successful treatment since?

Have you been hospitalized for an HIV-related reason in the past 2 years? *

Yes No

Is your viral load currently undetectable? *

Yes No Not sure

When was your last CD4 count and viral load blood test? *

Within 6 months 6-12 months ago More than a year ago Not sure

What did that test show for your viral load? *

Undetectable Detectable Not sure

How was HIV acquired? *

Are you free of Hepatitis B, Hepatitis C, and tuberculosis (TB)? *

Yes No Not sure

Do you see your doctor regularly for HIV follow-up care and testing? *

Yes No

Have you used tobacco or nicotine products in the last 5 years? *

Yes No

Which products? (select all that apply)

Cigarettes Cigars Vape / e-cigarette Nicotine gum or patch Marijuana Not sure / other

Are you still using it, or did you quit?

Still using I quit

What year did you quit?

Do you have any other major health conditions? *

Yes No

Which condition? (select all that apply)

Diabetes Heart disease, heart attack, or stroke High blood pressure or high cholesterol Cancer Kidney or liver disease / Hepatitis B or C Depression, anxiety, or other mental health condition COPD or other lung disease Sleep apnea Autoimmune disease (lupus, rheumatoid arthritis, MS) Seizure disorder or epilepsy Blood clot (DVT/PE) or clotting disorder Obesity or bariatric surgery Not sure / other

Have you used illegal drugs, or been advised to have (or received) treatment or counseling for alcohol or drug use? *

Yes No

In the past 2 years, have you had any medical test, procedure, or hospitalization that has not been completed, or for which you have not yet received the results? *

Yes No

In the past 10 years, any high-risk activities (private flying, scuba diving, racing, climbing), a felony, or a DUI? *

Yes No

Tell me a little about it

4Tell Me More

Best way to reach you

Call Text Email

Best time to reach you

Anything else you’d like me to know?

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By submitting, you agree to be contacted by Phillip Chin about life insurance options by phone, text, or email. Your information is kept private and is never sold. No obligation.

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