To report a loss, complete and submit the following:

	Date of Loss:	mm/dd/yyyy
	Time of Loss:	HH:MM
	Cause of Loss:
	Policy Number:
	Agency Number:
	Effective Date of Policy:	mm/dd/yyyy

 

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Insured Information:

	Insured Name:
	Property Address:
	City:	State:	Zip Code:
	Home Phone:	Business Phone:
	Cell Phone:	Email Address:
	Mortgage:

 

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Loss:

	Description of Loss & Damage:
	Reported By:	Reported Time:

 

DISCLAIMER: This submission does not commit the Kansas FAIR Plan and Columbia National Insurance Company, as Servicing Insurer for the Kansas FAIR Plan, to coverage for this loss. Information you submit regarding the insurance policy and the loss is subject to our review and verification. We reserve the right to request additional information prior to reaching a decision on the claim. A claim representative will be communicating with the insured regarding the claim. If you have any questions concerning the coverage afforded by the policy, please contact a claims representative at Columbia National Insurance Company.