Long Term Care Insurance

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Ruhm Insurance Agency, LLC / Chris Ruhm

I am partnered with a colleague in the insurance industry that only does LTC Insurance. He is the best in the industry. Filling this form out, you agree to allow Scott O. to give you a call and discuss your needs.

Name *

Contact Info (Email Address & Phone Number) *

Gender *

Male

Female

Birthday *

YYYY

State of Residence *

Do you have a spouse? *

Yes

Yes, and I'd like a quote for them. (Please have them fill out this form)

How is your health? *

Excellent

Above Average

Average

Below Average

Poor

What life stage are you in? *

Retired

Ready to Retire Soon

Within 5 Years of Retiring

Retiring in 5-10 Years

At least 10 years before retiring

Which statement suits you? *

LTC Insurance has been on my mind and I want a solid policy that will cover my life long long-term care expenses.

I'm looking for an affordable option that may allow me to purchase more coverage, but know it may not cover all my expenses.

I'm looking for a small policy and don't intend to get anything else.

I want home healthcare only, I don't want to go in assisted living and understand this policy will only cover me in the home.

I have no idea, let's discuss,

Do you currently own some type of Long Term Care *

Yes

Not Sure

Have you ever been declined for a LTC policy? If yes, please share in the next box below. It is not an automatic disqualification. *

Yes

Any other information you can share, health concerns, or questions you may have? *

How did you hear about us? *

Submit

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