| Report a Claim |
| Enter Policy No: |
| Enter Policy Holder Last Name: |
| Home/Cell Phone: | Other Phone: |
| Best Time to Contact: |
| Email Address: |
| Date of Loss:
| Time of Loss: |
| Reported By: | Reported to Agency:Yes No |
| Reported to KMIC By: | If Reported to Agency, date reported:
|
| Loss Location: Please enter Street Adress, City, State and Zip Code. |
|
| Loss Description: Please enter a detailed description of the occurence. |
|
|
| By submitting this claim request you are certifying that you have authority to make |
| this request by being the insured or a representative of the insured. |
| |
| Disclaimer: This claim will be reviewed and contact will be made as soon as possible. We may not |
| receive this promptly if the report is being completed after office hours or on weekends. This |
| reporting capability is solely for the convenience of filing a claim after hours or when it is not |
| feisible to contact your agent during normal business hours. |
| Fraud: It is a crime to knowingly provide false, incomplete or misleading information to an insurance |
| company for the purpose of defrauding the company. Penalties may include imprisonment, fines or |
| denial of insurance benefits. |