Lourie Life and Health

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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
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Do you have Original Medicare Part B?

Yes No
When did/does your Part B start?

Month Day Year
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Please select the following items that apply to you:

	Yes	No
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)?