Proof of Claim Form

IN THE MATTER OF CORNERSTONE NATIONAL INSURANCE COMPANY

Circuit Court of Cole County, MO. 25AC-CC08521 BAR DATE December 31, 2026

To participate in any distributions on timely claims, all claims must be received by the Liquidator on or before the Claim Filing Deadline of December 31, 2026. Claim forms sent via the U.S.P.S. or another carrier must be received no later than December 31, 2026. Forms submitted electronically must be received by the Liquidator by 11:59 p.m. on December 31, 2026. No persons having a claim against Cornerstone National Insurance Company shall participate in any distribution of assets unless such claims are received by the Liquidator on or before the Claim Filing Deadline of December 31, 2026, and subsequently approved by the Liquidator or the Court.

General Information

Claimant Name *

Claimant Address

Street Address *

Address Line 2

City *

State *

Zip Code *

Email Address *

Phone Number *

Attorney's Information (if applicable)

Claimant's Attorney Name (if applicable)

Street Address

Address Line 2

City

State

Zip Code

Email Address

Phone Number

Date of Claim or Invoice

Policy Information (If Applicable)

Policy Number

Insured Name (if different than claimant name)

Claim Class - Priority of Distribution

Policy Holders / Insured

Unpaid benefits arising under the coverage of a CNIC policy or contract

Unearned or refund premiums related to a CNIC policy

Claimants (Other than Policy Holders / Insureds)

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 amount (describe nature, itemized amounts and consideration in the claim narrative)

Claimants Additional Information

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

Yes No

Describe any prior payments made on the debt

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

Yes No

Is there security for the debt?

Yes No

Status of Claim

Current status of the claim *

Court Judgment or Settlement Date

Please provide details and documentation or reference items previously provided to CNIC

Claim Narrative

Provide a brief narrative detailing the basis of your claim *

Supporting Documents

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

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Signature

Date Signed *

Name of Claimant (Please type) *

By submitting this form, 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.

General Information

Claimant Address

Attorney's Information (if applicable)

Policy Information (If Applicable)

Policy Holders / Insured

Claimants (Other than Policy Holders / Insureds)

Claimants Additional Information

Status of Claim

Claim Narrative

Supporting Documents

Signature

Claim Submitted Successfully

Submission Failed