Long Term Care Insurance

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Ruhm Insurance Agency, LLC / (513) 335-2465 / info@chrisruhm.com

Please complete form below to the best of your knowledge. This is for quoting information purposes only. A final determination and rate would be determined in underwriting after a complete application is submitted. If you currently need assistance with bathing, toileting, transferring, eating, dressing or maintaining continence you need to call me so we can discuss alternatives.

Name *

State of Residence *

Birthday *

YYYY

Relationship *

Single

Married

Divorced

Widowed

Email Address *

Phone Number

Height & Weight *

Tobacco Use? (All Forms) *

Yes

Never

Quit less than 1 year ago?

Quit less than 3 years ago?

Quit more than 5 years ago?

Family History or Alzheimers or Dementia *

Yes

More than one family member

Stroke, TIA, Cancer, Diabetes or Heart Condition? *

Yes

Any other medical conditions of significance (COPD, Emphysema, Arthritis, Vision Problems, Back, Kidney, Liver, etc)? *

Yes

Please list any medications currently taking? *

Additional Information: Please elaborate on any questions above?

Estimated Assets in Retirement *

Less than $50,000

$50,000-$500,000

$500,00-$1,000,000

$1,000,000 +

Other:

How did you hear about us? Any additional pertinent info, use this space. *

Submit

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