Claim Request Form

The purpose of this form (“Form”) is to allow anyone who maintains that they have been damaged because of the actions of Pavement Restorations, Inc., Inc. (“Company”) to present a claim for damages (“Claim”) to the Company. The failure to complete this Form completely, provide accurate information relating to the Claim and/or provide all documentation requested by this Form may result in a denial of the Claim. After the Form has been submitted and all supporting documentation for the Claim has been provided, a representative of the Company will contact the claimant (“Claimant”) by phone or at the email address provided by the Claimant.