Home / AEQUALIS Life Insurance Request AEQUALIS Life Insurance Request Aequalis Step 1 of 2 50% Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Sex*MaleFemaleDate of birth* Date Format: MM slash DD slash YYYY What type of life insurance are you looking for?*Term Life InsuranceWhole Life InsuranceSmall Final Expense policyAmount of Life Insurance death benefit desired?*Less than $25,000$25,000-$50,000$100,000 - $250,000$500,000 - $1,000,000$1,000,000 - $1,500,000$1,500,000 - $2,000,000More than $2,000,000Do you have a checking account?*Yes, I have a checking accountNo, I do not have a checking accountFor this type of policy, a checking account for monthly premiums to be withdrawn from is required. Nicotine Smoker or Vapor?*YesNoNumber of years ago that HIV diagnosis was made?*1 year2 years3 years4 years5 yearsMore than 5 yearsVirus acquired by blood transfusion or intravenous drug use?*YesNoYears of treatment with antiretroviral therapy (ART) without any lapses or delays in treatment?*One yearTwo yearsThree yearsFour yearsFive yearsMore than 5 yearsDo you have continuous monitoring by a qualified physician?*YesNoDo you have an undetectable HIV viral load for at least two years?*YesNoCD4 count of 350 cells/mm3 or higher for at least two years including a current CD4 count?*YesNoPrior history of (check all that apply)* Hepatitis B and/or hepatitis C infection, with proof of negative test results? Resistance to antiretroviral medication? Alcohol and/or drug (illicit or prescription) abuse? Coronary artery disease or significant psychiatric conditions? Diabetes Cancer Kidney Disease Multiple Sclerosis Chronic Obstructive Pulmonary Disease (COPD) Cerebral Vascular Disease or Stroke None of the above How often do you exercise?* 1-2 times per week 3-5 times per week Rarely Anything else we should know?