Clarence M. Kelly & Associates, Inc. Home

Case assignment form

For your convenience, we have added a new online case assignment form. It is customer friendly and will expedite your case activity with CMKA. The links to this form are located at the top of each page and in the left menu under each service offering.
As always, your feedback is welcome. Please feel free to send your comments to Rod Smith, Vice President of Marketing, rsmith at cmka dot com.

Customer / Client Information
Please supply your full contact information.
First Name:
Last Name:
Company:
 (if applicable)
Address:
Address 2:
City:
State:
Zip:
Country:
 (if not U.S.)
Telephone:
 (include area code)
Fax:
Email Address:
Preferred Method:
Phone Email Mail Fax
Claim #:
Date of Loss:
Type of Matter
Please choose one that best describes your request.
Case Type:
Other:
 (please specify)
Subject Details
Please provide as much information as possible about the subject or your investigation.
Name:
Name of Company:
(Last Known) Address:
Address 2:
City:
State:
Zip:
Country:
 (if not U.S.)
Telephone:
Gender:
 Male Female
Social Security #:
Date of Birth:
or Approximate Age:
Spouse's Name:
Children:
 Yes No
Identifying Features
Height:
 feet inches
Weight:
 lbs.
Hair Color:
Hair Length/Style:
Eye Color:
Race:
 (white, black, hispanic...)
Distinguishing Marks:
(scars, tattoos...)
Vehicle/s:
Pictures Avail:
 Yes No
Please include below ANY further information you know about the subject. EVERY detail you can give may help us solve your case more quickly and efficiently.
Other Details:

 
Your Partner in Security Solutions and Risk Management
7945 Flint      Lenexa, KS 66214      p. 913.647.7700      f. 913.647.7710      info@cmka.com