Kansas Mutual Insurance Company
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: 
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Time of Loss: 
Reported By: Reported to Agency:Yes No
Reported to KMIC By:  If Reported to Agency, date reported:
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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.