This form together with your name, our company's name and lot number, are to be given without comment or delay to anyone ("Claimant") making a claim against Valet King for auto damages, property damages, thefts, or personal injuries. If the Claimant is unwilling or unable to cooperate, you should immediately fill out this form to the best of your ability and mark an "X" here:
1. We sincerely regret any problems that you may have experienced as a possible result of our service. This form, when completed by you, will provide the information and signature required to begin processing your claim.
2. Our Employees are not authorized to admit or deny the validity of your claim. They are authorized only to present and accept this form. Our presentation and acceptance of this form is neither an admission nor denial of responsibility.
3. The applicable sections of this form must be completed to the best of your ability and submitted promptly in person to our employees at the location of the alleged incident.4. It is a felony to present fraudulent claims to an insurance company.