warranty claim form

- All fields are required unless otherwise indicated

Job Information

Pour Date

Job Title

Ticket Number(s) in Dispute

Invoice Number in Dispute

Load Count in Dispute

Yard Count in Dispute

Contact Information

Claimant (Company)

Claimant is Representing (Optional)

Claimant (Contact Person)

Claimant Email Addresss

Claimant Phone Number

Business Address

Address Line 1

Address Line 2

City

State

Postal Code

Contact on Site

Job Address (If Different)

Address Line 1

Address Line 2

City

State

Postal Code

Contact on Site

Claim Type

Quality

Yield

Delivery/Service

Pricing/Billing

Supporting Documents

Required Supporting Documents (Claims without proper support are subject to denial):

Photos of placement and final condition

Copy of delivery ticket(s) for all loads in question

Quote/Contract (Only document required for pricing/billing dispute - not required for other dispute types)

Inspection: Hercules Concrete requires third party test data to process warranty claims

Third Party tester contact information

Third Party test results

Description of Issue

Document upload

Upload File(s)

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Uploaded File(s):

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I acknowledge that the information provided is accurate to my knowledge, and that failure to submit complete and accurate documentation, including third party test data, may result in denial of this claim.

Claims will not be evaluated unless accompanied by all required documentation.

All claims must be submitted within 35 days of delivery unless further restrictions apply.

Once a claim is submitted, please allow up to 30 days for processing and review.

Claims cannot be paid until account is in good standing.

Any processed claims will be applied as a credit on future work.

For additional details, refer to the Hercules Concrete Terms and Conditions posted at www.herculesconcrete.com

Please direct all claims related correspondence to: claims@herculesconcrete.com

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