File a Claim - westandknox

West and Knox Mutual Insurance Company

355 Leatherberry Road SE, Carrollton, OH 44615

(330) 627-0230

General Information

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Name of Insured *

Date of Initial WK Notice *

Contact Name *

Insured's Address *

Address Line 1

City

State

Zip Code

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Phone *

Policy Number *

Best Time of Day to Contact

Effective Policy Date *

Policy Type

Coverage

Deductible

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Mortgage *

Yes
No

Mortgage Lender *

Loss Information

Date / Time of Loss *

Date

Time

Address of Loss *

Address Line 1

City

State

Zip Code

Type of Loss *

Description of Loss *

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

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Insured's Signature *

Date *

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Insured's Signature *

Date *