Proof of Claim Form IN THE MATTER OF Cameron Mutual Insurance Company (Circuit Court of Cole County, MO. 23AC-CC04735) BAR DATE MARCH 29, 2024

To participate in any distributions on timely claims, all claims must be received by the Liquidator on or before the Claim Filing Deadline of March 29, 2024. Claim forms sent via the U.S.P.S. or another carrier must be received no later than March 29, 2024. Forms submitted electronically must be received by the Liquidator by 11:59 p.m. on March 29, 2024. No persons having a claim against Cameron Mutual Insurance Company ("CMIC") shall participate in any distribution of assets unless such claims are received by the Liquidator on or before the Claim Filing Deadline of March 29, 2024, and subsequently approved by the Liquidator or the Court.

General Information

Please provide your general information

Claimant Address

Please provide the address of the claimant

Attorney's Address

If applicable, please provide the address of the attorney

Classes of claims - priority of distribution. The priority of distribution of claims from the insurer's estate shall be in accordance with the order in which each class of claims is herein set forth. Every claim in each class shall be paid in full or adequate funds retained for such payment before the members of the next class receive any payment. No subclasses shall be established within any class. No claim by a shareholder, policyholder or other creditor shall be permitted to circumvent the priority class through the use of equitable remedies. The order of distribution of claims shall be:






















Policy Holders / Insured

Enter the dollar amount for each category below as applicable or if not know "unknown"

Claimants (Other than Policy holders) / Insureds

Enter the dollar amount for each category below as applicable or if not know "unknown"

Claimants Additional Info

Additional information about the claim

Status Of Claim

Current status of the claim

Supporting Document

EACH PROOF OF CLAIM MUST HAVE ATTACHED ALL SUPPORTING DOCUMENTATION OR REFER TO DOCUMENTATION PREVIOUSLY FILED WITH THE LIQUIDATOR TO BE CONSIDERED.

Undersigned subscribes and affirms as true under the penalties of perjury as follows in filing this claim: That he/she has read the foregoing Proof of Claim and knows the contents thereof; that this claim is justly owing to claimant; that there are no setoffs, counterclaims or defense to the claim, and that the matters set forth in any accompanying documents are true to the best of his/her knowledge and belief.