General Information     First Name: Last Name: E-mail:     Street Address: City: State: Zip : How many years have you lived at current address? Less than 1 1 2 3 4 5 5 or more Do you own your home? Yes No Daytime Phone: Evening Phone: What type of Insurance are you interested in? Auto Health Life Disability Commercial Home Owner's Annuities Marital Status: Single Divorced Married Civil Union Separated< 1 Year Separated 1 Year or More Widowed Do you have any children under the age of 18? Yes No Please specify your employer: A private company or organization The federal government Serving in the military A state government A local or municipal government Currently a homemaker Not currently employed Self-employed Retired from a private company or organization Retired from the federal government Retired from the military Retired from a state government Retired from a local or municipal government Are you a full time student? Yes No