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Claim Request

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Claim Request

CLAIM REQUEST

Please complete the following application and submit to King Asphalt, Inc. Applications can be submitted online, in person at the office, mailed, faxed, or emailed.
Date of Incident
Claimant Name
Claimant Address
Claimant Phone Number(s)
Location of Incident
Time of Incident
If this incident did not involve a vehicle, please continue to next section (Describe the Incident) Vehicle Description (Make, Model, Year, VIN)
Vehicle Owner’s Name and Phone Number
Email*
Name and Phone Numbers of Passengers
Name of Anyone Injured
Describe the Injuries
Was Emergency Medical Treatment Required? If so, by whom?
Was Law Enforcement Called? If so, what agency? Is there a Police Report Number?
Description of Damages to Vehicle (Please attach photos if available)
Estimated Value of Damages
Is vehicle operable? If not, provide location and phone number of vehicle location.
Weather Conditions at Time of Incident:
Describe the Incident
Describe any Damage to Property other than Automobile
By signing this document, I attest that it is a true account of the above described incident.
Name (Printed)
Signature
Date
Instructions & Additional Information
Completing the Claim Request;
- Claim Requests can be found on the King Asphalt, Inc. website (www.kingasphaltinc.com). Additional copies may be requested at the main office.
- All Claim Requests must be completed to begin the claims process. Any incomplete forms will be returned for completion.
- All claims must be made within five (5) days of the incident.
- Within four (4) business days of submitting the complete Claim Request, you will be contacted by a representative of King Asphalt, Inc.
- If you have not been contacted by a representative of King Asphalt, Inc. within four (4) business days of submitting the request, please call the main office at (864) 855-0338 for assistance.
Submitting the Claim Request;

• Claim Requests shall be submitted to the Main Office
- Deliver: 2127 Greenville Highway, Liberty SC 29657
- Mail: Attn: Claims Reporting, P.O. Box 179, Liberty SC 29657
- Fax: Attn: Claim Reporting, (864) 843-2147

Claim Request

CLAIM REQUEST

Instructions & Additional Information