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Long Term Care Insurance
Ruhm Insurance Agency, LLC / (513) 335-2465 /
info@chrisruhm.com
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.
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Full Name
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Your answer
State of Residence
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Your answer
Birthday
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MM
/
DD
/
YYYY
Relationship
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Single
Married
Divorced
Widowed
Email Address
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Your answer
Phone Number
Your answer
Estimated Assets in Retirement
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Less than $50,000
$50,000-$500,000
$500,00-$1,000,000
$1,000,000 +
Other:
Have you ever been declined for a LTC policy? If yes, why?
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Your answer
Height & Weight
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Your answer
Tobacco Use? (All Forms)
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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
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Yes
No
Yes, more than one immediate family member (parents/grandparents)
Stroke, TIA, Cancer, Diabetes or Heart Condition?
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Yes
No
Any other medical conditions of significance (COPD, Emphysema, Arthritis, Vision Problems, Back, Kidney, Liver, etc)?
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Yes
No
Please list any medications currently taking, the condition and prognosis?
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Your answer
Any other information or conditions of concern?
Your answer
How did you hear about us?
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Your answer
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