Lourie Life and Health

Medicare Questionnaire
Name (Required) *

First Name Last Name
Birth Date

Month Day Year
Date
Phone Number

Area Code Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
MyMedicare.gov

Do you have an account on mymedicare.gov? If so, please provide your credentials below:
Username
Password
Disclaimer:

A sales agent may mail, call or e-mail as a result of completing the information to discuss Medicare Advantage, Prescription Drug Plans or Medicare Supplement Insurance.
Do you have Original Medicare Part A?

Yes No
When did/does your Part A start?

Month Day Year
Date
Do you have Original Medicare Part B?

Yes No
When did/does your Part B start?

Month Day Year
Date

Please select the following items that apply to you:

Yes

Do you have a group health plan?

Do you qualify for Medicaid?

Do you qualify for Extra Help?

What prescriptions (not OTC) do you take regularly (include dosage/frequency)?

Name

Dosage

Frequency