Proof of Claim Form

General Information

Please provide your general information

Claimant Name:

Claimant Address

Please provide the address of the claimant

Street Address: Address line 2: City: State: Zip Code: Email Address: Phone Number:

Claimant's Attorney Name (if applicable):

Attorney's Address

If applicable, please provide the address of the attorney

Street Address: Address line 2: City: State: Zip Code: Email Address: Phone Number:

Date of Claim or Invoice: Policy Number: Insured Name: (if different than claimant name)

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:

Class 1. The costs and expenses of administration during rehabilitation and liquidation, including but not limited to the following:

The actual and necessary costs of preserving or recovering the assets of the insurer, and costs necessary to store records required to be preserved pursuant to section 375.1228
Compensation for all authorized services rendered in the rehabilitation and liquidation
Any necessary filing fees
The fees and mileage payable to witnesses
Authorized reasonable attorney's fees and other professional services rendered in the rehabilitation and liquidation
The reasonable expenses of the Missouri Property and Casualty Insurance Guaranty Association, the Missouri Life and Health Insurance Guaranty Association, and any similar organization in any other state, including overhead, salaries, and other general administrative expenses allocable to the receivership. These expenses shall be subordinate to all other costs and expenses of administration under paragraphs (a) to (e) of this subdivision. The provisions of this paragraph shall apply to the distribution of claims from an insurer's estate if such insurer was first placed under an order of rehabilitation or an order of liquidation if no order of rehabilitation was entered on or after August 28, 2018

Class 2. All claims under policies including such claims of the federal or any state or local government for losses incurred ("loss claims") including third party claims and all claims of a guaranty association or foreign guaranty association including reasonable allocated loss adjustment expenses and all claims of a life and health insurance guaranty association or foreign guaranty association which covers claims of life and health insurance policies, relating to the handling of such claims. All claims under life insurance and annuity policies and funding agreements, whether for death proceeds, annuity proceeds or investment values shall be treated as loss claims. That portion of any loss, indemnification for which is provided by other benefits or advantages recovered by the claimant, shall not be included in this class, other than benefits or advantages recovered or recoverable in discharge of familial obligation of support or by way of succession at death or as proceeds of life insurance, or as gratuities. No payment by an employer to his employee shall be treated as a gratuity. Early distributions to guaranty associations and foreign guaranty associations may be made in the manner provided in section 375.1205, provided that such guaranty associations and foreign guaranty associations agree to indemnify the liquidator if a shortage occurs in the insurer's estate of property necessary to settle claims as provided by this section. Any early distributions shall not increase the proportionate share of such guaranty associations and foreign guaranty associations, of distributions of the insurer's estate. The liquidator shall have authority to inquire into the reasonableness of any allocated loss adjustment expenses claimed by a guaranty association or foreign guaranty association and such claim shall not be allowed if it is found to be unreasonable.

Class 3. Claims of the United States government other than those claims included in class 2.

Class 4. Reasonable compensation to employees for services performed to the extent that they do not exceed two months of monetary compensation and represent payment for services performed within one year before the filing of the petition for liquidation or, if rehabilitation preceded liquidation, within one year before the filing of the petition for rehabilitation. Principal officers and directors shall not be entitled to the benefit of this priority except as otherwise approved by the liquidator and the court. Such priority shall be in lieu of any other similar priority which may be authorized by law as to wages or compensation of employees.

Class 5. Claims under nonassessable policies for unearned premiums or other premium refunds and claims of general creditors including claims of ceding and assuming companies in their capacity as such.

Class 6. Claims of any state or local government except those under class 2 of this section. Claims, including those of any governmental body for a penalty or forfeiture, shall be allowed in this class only to the extent of the pecuniary loss sustained from the act, transaction, or proceeding out of which the penalty or forfeiture arose, with reasonable and actual costs occasioned thereby. The remainder of such claims shall be postponed as class 9 claims.

Class 7. Claims filed late or any other claims other than class 8 or 9 claims.

Class 8. Surplus or contribution notes, or similar obligations, and premium refunds on assessable policies. Payments to members of domestic mutual insurance companies shall be limited in accordance with law.

Class 9. The claims of shareholders or other owners in their capacity as shareholders.

Policy Holders / Insured

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

Unpaid benefits arising under the coverage of a CMIC policy or contract:

Unearned or refund premiums related to a CMIC policy:

Claimants (Other than Policy holders) / Insureds

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

U.S. Government claims:

Secured claim:

Salary or wages for services performed:

Governmental entity claim for penalties or forfeitures:

Unpaid legal or professional expenses:

Unpaid commissions or general creditor invoices:

All other claimants (On a separate sheet describe nature, amount and consideration related to each claim):

Claimants Additional Info

Additional information about the claim

Do you assert this claim is entitled to priority under § 375.1218, RSMo?

Identify the applicable subsection and reason for the priority amount:

Describe any prior payments made on the debt:

Are there set-offs, counterclaims or defenses to the debt?

Describe set-offs, counterclaims or defenses:

Is there security for the debt?

Description of Debt Security:

Value of Security:

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.

Upload supporting documents (if any):

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.

Date Signed: Name of claimant (Please type):

Proof of Claim Form IN THE MATTER OF Cameron Mutual Insurance Company (Circuit Court of Cole County, MO. 23AC-CC04735) BAR DATE December 31, 2024

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

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.