Long Term Care Insurance
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. Please call me at (513) 335-2465 and do not fill out if you need assistance currently or anticipate needing in the next year help with bathing, toileting, transferring, eating, dressing or maintaining continence.
Name *
Your answer
State of Residence *
Your answer
Birthday *
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DD
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YYYY
Relationship *
Email Address *
Your answer
Phone Number
Your answer
Height & Weight *
Your answer
Tobacco Use? (All Forms) *
Family History or Alzheimers or Dementia *
Stroke, TIA, Cancer, Diabetes or Heart Condition? *
Any other medical conditions of significance (COPD, Emphysema, Arthritis, Vision Problems, Back, Kidney, Liver, etc)? *
Please list any medications currently taking? *
Your answer
Additional Information: Please elaborate on any questions above?
Your answer
Estimated Assets in Retirement (Optional)
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