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 CWR Contracting, 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.

"*" indicates required fields

Claimant Name*

First Last

Claimant Representative (attorney or person submitting Claim for Claimant)

First Last

Claimant Mailing Address*

Street Address Address Line 2 City State ZIP Code

Representative Mailing Address

Street Address Address Line 2 City State ZIP Code

Claimant Phone Number*

Claimant Phone Number Type (Select)*

Alternative Claimant Phone Number

Alternative Claimant Phone Number Type (Select)

Representative Phone Number*

Representative Phone Number Type (Select)*

Claimant Email Address*

Representative Email Address

Describe in detail all facts and circumstances that support the Claim (“Incident”). If there is insufficient room below to describe the Incident, attach a separate written or typed statement that describes the Incident to this Form.*

Provide the exact location of the Incident (e.g., in the outside, southbound lane of Davis Drive in Ocala, Marion County, FL, south of the intersection of Davis Drive and Airport Boulevard and directly in front of Publix Grocery Store).*

Date of Incident*

Time of Incident*

On the date and time of the Incident, what were the weather conditions (e.g., sunny and clear, dark and rainy, etc.)?*

If the Claimant maintains that they have suffered monetary loss or damage because of the Incident, provide the exact amount of that loss and itemize that loss by category (e.g., Car Repair, Rental Car, etc.). If the Claimant has any documentation to support a claim for monetary loss or damage (invoices, estimates, photographs, etc.), attach that documentation with this Form.*

Does the Claimant maintain that anyone other than the Company, in part or in whole, caused the Claimant to suffer monetary loss or damage because of the Incident? If so, describe in detail the basis for that additional claim and attach all documentation that supports the basis for that additional claim.*

Are there are any witnesses other than the Claimant to the Incident? If so, provide their name and all known contact information (telephone number, address, email address, etc.).*

Does the Claimant have any photographs that support, refute, or relate to the Incident or alleged damages associated with the Incident? If so, attach those photographs to this Form.

Does this Incident relate to any damage to any vehicle? If so, provide, if known, the name, address, telephone number and email address for the owner each vehicle involved in the Incident (including any Company vehicle) as well as the make, model, year, color, current mileage, and VIN (Vehicle Identification Number) for each vehicle involved in the Incident.*

Was a piece of Company equipment (separate from a vehicle) involved with the Incident? If so, describe in detail the piece of equipment (e.g., make, model, year, color, identifying logo) for each piece of equipment involved in the Incident.*

Prior to submitting this Form, did the Claimant at any time communicate with any representative of the Company regarding this Incident? If so, provide the name, title, and contact information of any Company representative that the Claimant communicated with, and describe in detail all matters communicated between the Claimant and the Company representative.*

Was any law enforcement officer or any other government representative notified of this Incident? If so, provide the name, title, and contact information of the law enforcement officer of other government representative notified of this Incident, describe in detail all matters communicated between the Claimant and law enforcement officer of other government representative, and attach to this form all documentation received from the law enforcement officer of other government representative (e.g., police report, driver exchange form, letters, etc.).*

Was anyone injured because of this Incident? If so, describe in detail all alleged injuries as well as all medical treatment administered, provide the name(s) of person(s) that received treatment, the name(s) of all health care providers, the location(s) of any facility where medical care was provided, and attach to this form all documentation (invoices, medical care notes, etc.) that relate to any medical care provided because of the Incident.*

Does the Claimant have any additional documentation that relates to the Incident not requested above? If so, attach all such documentation to this form.*

Are there any other details that the Claimant maintains would support the Claim. If so, describe those details below.*

Attach all documents described or requested above here.

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