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:
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Loss Location: Please enter Street Adress, City, State and Zip Code. |
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Loss Description: Please enter a detailed description of the occurence. |
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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. |
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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. |