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Kansas Insurance Loss Policy

  1. Insured
  2. Last, First, Middle Initial
  3. Last, First, Middle Initial
  4. Location of Loss
  5. Print "Same" if insured's current address
  6. Insured By
    Report ONLY those items involved and omit cents
  7. Amount of Policy
  8. Total Insurance
  9. Replacement Cost Value
  10. Actual Cash Value
  11. Loss Information
  12. Known Cause of Loss/Fire
  13. Type of Property
  14. Check:
  15. Vehicle Information
  16. Cropland Information
  17. If bales, provide size or weight of bale
  18. Other Parties to the Loss
    If a business, please enter full name of business.
  19. Enter Applicable Code
    1-Partner, 2-Agent, 3-Attorney, 4-Corporate Officer, 5-Second Mortgages, 6-Public Adjuster, 8-Tenant, 9-Occupant, 10-First Mortgage, 11-Other
  20. Last, First, Middle Initial
  21. Last, First, Middle Initial
  22. Adjuster
  23. By typing your name and date below, you certify that you provided the above information and to the best of your knowledge, information and believe, all of such information is accurate.
  24. Leave This Blank:

  25. This field is not part of the form submission.