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Claim Form:  

First & Last Name:  
Street Address:  
City, State & Zip:  
E-Mail Address:  
Telephone:  
Fax:  

Date of Loss:  


Time of Loss:  

Location of Incident/Loss:  
Description of Incident/Loss:  
Were the authorities called:  
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106 S. Penn
Oberlin, Ks 67749
Tel: (785) 475-3310
Fax: (785) 475-8965
117 N. Kansas
Norton, KS 67654
Toll Free: 866-484-6236
Tel: 785-877-4016
Fax: 785-874-4832
PO Box 235
101 Front St.
Winona, KS 67764
Tel: (785) 846-7476
Fax: (785) 846-7479