UMT$-$LMS

Health Insurance Information Form

Email

Street Address

Does your employer offer health

Do you receive Medicare? insurance?

Yes

Yes

No

No

You are building the website for an insurance company. Build a web page of the company which contains a HTML form. Theough this form insurance company gather valuable information about their potiential clients.

Your HTML form must contain at least $20$ different input fields. Like this in given picture.