HIV Life Assurance - working hard for people with HIV

Life assurance explained

Finding life assurance if you're HIV+ used to be impossible. No 'High Street' insurer provides such a policy. We can. And you no longer have to be on medication to be able to be covered like before!

Based on the initial, relatively small amount of information required at this stage, an indicative premium can be calculated, based on your individual circumstances. If you would then like to go ahead, more detailed information will be required and then a definitive premium will be given to you.

Simply complete the form and we will get back to you as quickly as possible with the indicative premium.

Life assurance (or term assurance) is a life insurance policy that runs for a specified period of time. Payouts from term assurance are tax-free and will only be paid out to your estate or beneficiaries if the life assured dies within the policy term.

This is a straightforward life assurance policy that guarantees a lump sum payment of the total sum assured if the policyholder dies within the policy term. The premium remains the same throughout the period of assurance. For detailed information, please click here.

We can also provide the following types of policy (click each for detailed information):

Whole of Life

Gift Inter Vivo

Family Income Benefit

PLEASE ANSWER ALL QUESTIONS UNLESS NOT APPLICABLE, OTHERWISE THE INSURERS WILL NOT BE ABLE TO PROVIDE YOU WITH A QUOTE. THANK YOU.
ILLUSTRATION OPTIONS
Do you want single or joint cover?
PERSONAL DETAILS
	First life assured	Second life assured
Title
If other, please specify
First name
Last name
Gender
Date of birth (dd/mm/yy)
Nationality
Are you a UK resident?
Full address
Telephone number
E mail
Do you drink alcohol?
If so, what is your weekly consumption? (a unit of alcohol is equivalent to half a pint of normal strength beer, lager or cider, one standard glass of wine or a single measure of spirit)	units	units
Have you been advised by a member of the medical profession to reduce your intake?
Have you smoked or used any tobacco or nicotine product in the last 12 months? Please note, the insurers may require a test to confirm your non-smoking status.
If yes, what is your average weekly consumption? (eg amount and type: 100 cigarettes, 4ozs pipe tobacco, 20 cigars)
What is your height?	ft ins OR cms	ft ins OR cms
What is your weight?	st ozs OR kgs	st ozs OR kgs
PLAN DETAILS
Type of policy required
You must tell us how much you want the life assurance policy to cover you for or the amount of monthly premium you wish to pay, so one of the next two questions must be answered:
Sum assured or annual income if FIB
OR monthly premium payable
Policy term (maximum is currently 10 years)	years	years
If joint life, should the sum assured be payable upon:
Premium payment payable
PREVIOUS COVER
Has any proposal for life cover been declined or postponed?
If yes, please give us the date
Company that declined/postponed cover
Reason why (if known)
If postponed, for how long?
Are there any proposals for life assurance benefits currently being made to other insurers?
If so, please provide details
HAZARDOUS ACTIVITES
Sports/pastimes - please provide full details if you take part in any hazardous sports/passtimes
What is your current occupation?
If you work at heights, underground, underwater or offshore, please provide full details
Are you unable to work for medical reasons?
Have your parents, brothers or sisters, before age 65, died or suffered from heart disease, stroke, high blood pressure, diabetes, kidney disease, cancer, multiple sclerosis, paralysis or any hereditary disorder?
If so, please indicate the age of the relative when they first suffered the condition and details of the condition itself including, for cancer, the part of the body affected.
DETAILS ABOUT HIV HEALTH CONDITION
When was your first positive HIV test result?
Date of Infection (if known)
Have you had any HIV-related illnesses or symptoms, such as pneumonia, diarrhoea, night sweats, etc.?
Please provide full details
Please give your latest CD4 count
Please give your latest viral load count
What treatments or investigations have you had, including dates?
What medication are you currently taking, including its name and quantity?
Have you ever taken drugs, other than “over the counter” medicine or as prescribed by a qualified doctor?
Have you ever suffered from hepatitis B or C?
If you have any other health conditions, please give details below
OTHER HEALTH CONDITION 1
Name of condition, illness or injury
Date diagnosed
Treatments, including dates
Medication, including name and quantity
OTHER HEALTH CONDITION 2
Name of condition, illness or injury
Date diagnosed
Treatments, including dates
Medication, including name and quantity
OTHER HEALTH CONDITION 3
Name of condition, illness or injury
Date diagnosed
Treatments, including dates
Medication, including name and quantity
OTHER HEALTH CONDITION 4
Name of condition, illness or injury
Date diagnosed
Treatments, including dates
Medication, including name and quantity
FURTHER INFORMATION
Please give us any other information you think might be relevant

Sponsor of the Scotland Patients' Association Member of the British Insurance Brokers' Association Authorised and Regulated by the Financial Services Authority Member of the International Gay & Lesbian Chamber of Commerce Member of the International Lesbian & Gay Travel Association A Partner in the Foreign & Commonwealth Office's Know Before You Go Campaign.