Secure Futures Insurance Agency 8700 West Bryn Mawr Suite 600 South Chicago, Illinois 60631 Phone: 773-380-9700 Fax: 773-380-9711 e-mail : sfia@securefuturesinsur.com Today is
	Please fill out the information below. Name Address   City State   Zip Code E-mail Address Social Security Number   Telephone   Work Telephone   Present Carrier   Premium   Exp. Date   County   Please identify the name of the agent that referred you to our website: Has your Homeowners Insurance ever been canceled or non renewed? No Yes If Yes, please provide details below: Have you had any property or liability losses in the last 3 years? No Yes If Yes, please provide details below:  Date:   Amount: Circumstances:  Date:   Amount: Circumstances: Type:   Single Home   2 Flat Townhouse     Apartment Condominium Construction (Please check one)   Masonry   Frame Fire Resistive    Other: Year Built  Number of Units   Dwelling Replacement Cost Value   Contents Coverage (Condo or Apt)   Additions/Alterations   Deductible Select $250 $500 $1,000 Other Personal Liability Select $100,000 $300,000 $500,000 Other Medical Payments Select $1,000 $5,000 Other Security:   Deadbolts  Smoke Detectors   Fire Extinguisher Fire Alarm Burglar Alarm Central Station Alarm Local Alarm Scheduled Valuable Items: Limit    Jewelry          Silver        Furs        Guns        Fine Arts     Are all members of the household non-smokers? Select Yes No Do you own any other property or land? Select Yes No If yes, please describe: Is it separately insured? Select Yes No If yes: Insurer Limit Do you conduct any business activities in your home or garage? Select Yes No If yes, please describe: Do you have any domestics? Select Yes No If yes, please describe: Do you want water back up coverage? Select Yes No If yes: $5,000 $10,000 Do you want ordinance or law coverage? Select Yes No Would you like an umbrella quote? Select Yes No Would you like a flood insurance quote? Select Yes No