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.
Medicare Questionnaire
Do you have Original Medicare Part A?

Yes No
When did/does your Part A start?

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

Yes No
When did/does your Part B start?

- Month - Day Year
Date Date Picker Icon

Please select the following items that apply to you:

	Yes	No
Do you have group health plan?
Do you qualify for Medicaid?

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

Medicare Questionnaire