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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.