47QMCA23R0011 Attachment V2 - DIT Claim Form Template (Purchasing).pdf

8/5/2021 Damage in Transit Claim Reporting Form https://docs.google.com/forms/d/1DLappepVClPaZMNMC8NihAu11vRxaYRN_qgKsZT-Nr8/edit 1/10

1. Email *

Your Information

2.

3.

Consignee (Customer) Information

4.

5.

Damage in Transit Claim Repo�ing Form Please complete the following form in order to submit your Damage in Transit (DIT) Claim to GSA Fleet. All forms must be fully complete and accurate in order to be processed.

Incomplete or inaccurate forms will be summarily rejected. For any further questions, please e-mail vehicle.claims@gsa.gov.

* Required

Your Name *

Your Phone Number *

Consignee (Customer) Point of Contact Name *

Consignee (Customer) Point of Contact Email Address * mailto:vehicle.claims@gsa.gov https://docs.google.com/forms/d/1DLappepVClPaZMNMC8NihAu11vRxaYRN_qgKsZT-Nr8/edit 2/10

6.

Vehicle Receipt Information

7.

8.

9.

10.

11.

12.

13.

Consignee (Customer) Point of Contact Phone Number *

Name of Person Who Received the Vehicle(s) *

Agency Name *

Bureau Name *

Receipt Location Address *

Receipt Location's Point of Contact Name *

Receipt Location's Point of Contact Email Address *

Receipt Location's Point of Contact Phone Number * https://docs.google.com/forms/d/1DLappepVClPaZMNMC8NihAu11vRxaYRN_qgKsZT-Nr8/edit 3/10

Vehicle Information

14.

15.

16.

Customer Agency Fleet Information

17.

18.

19.

Delivery Information

20.

Example: January 7, 2019

Name of Vehicle Supplier *

RPN/Order Number *

Full VIN *

Name of Customer Agency Fleet Manager *

Email Address of Customer Agency Fleet Manager *

Phone Number of Customer Agency Fleet Manager *

Date Received * https://docs.google.com/forms/d/1DLappepVClPaZMNMC8NihAu11vRxaYRN_qgKsZT-Nr8/edit 4/10

21.

Mark only one oval.

Yes

No

22.

Example: January 7, 2019

23.

Mark only one oval.

Other:

Accepted

Rejected

24.

25.

Damage Information

Was the Vehicle Delivered During Normal Business Hours? *

Date Damage Was Noticed *

Was Vehicle Accepted or Rejected at Delivery? *

Current Address Where Vehicle is Located *

Transportation Company and Driver's Name * https://docs.google.com/forms/d/1DLappepVClPaZMNMC8NihAu11vRxaYRN_qgKsZT-Nr8/edit 5/10

26.

GSA Fleet Damage Code Reference Sheet

Description of Damage * https://docs.google.com/forms/d/1DLappepVClPaZMNMC8NihAu11vRxaYRN_qgKsZT-Nr8/edit 6/10

27.

Check all that apply.

10 - Door-Left Front

11 - Door-Left Rear

14 - Fender-Left Front

15 - Quarter Panel/Pickup Box-Left

30 - Mirror-Outside Left

35 - Rocker Panel/Outer Sill-Left

38 - Running Board/Step-Left

70 - Center Post-Left

01 - Antenna/Antenna Base

18 - Front Floor Mats

19 - Rear Floor Mats

23 - Accessory Bag/Box

40 - Spare Tire/Wheel

52 - Deck Lid/Tailgate/Hatchback

55 - Cargo Area/Other

57 - Wheel Covers/Caps/Rings

09 - Door-Right Cargo

12 - Door-Right Front

13 - Door-Right Rear

16 - Fender-Right Front

17 - Quarter Panel/Pickup Box-Right

31 - Mirror-Outside Right

36 - Rocker Panel-Outside Sill-Right

39 - Running Board/Step-Right

69 - Center Post Right

76 - Right Rear Tire

77 - Right Rear Wheel/Rim

78 - Right Front Tire

79 - Right Front Wheel/Rim

03 - Bumper/Cover/Ext-Front

05 - Bumper Guard/Strip-Front

20 - Glass Windshield

22 - Grille

24 - Headlight/Cover/Turn Signal

25 - Lamps-Fog/Driving/Spot

Please Select All Applicable Damage Area Codes as Referenced in the Above Diagram: * https://docs.google.com/forms/d/1DLappepVClPaZMNMC8NihAu11vRxaYRN_qgKsZT-Nr8/edit 7/10

Other:

27-Hood

42 - Splash Panel/Spoiler-Front

59 - Wipers, all

80 - Cowl

02 - Battery/Box

99 - Engine Compartment-Other

37 - Roof

53 - Sunroof/T-Top

56 - Vinyl/Convertible Top/Tonneau Cover

64 - Spoiler/Deflector-Rear

65 - Luggage Rack (Strips)/Drip Rail

71 - Corner Post

68 - Carpet-Front

85 - Communication/GPS Unit

93 - Steering Wheel/Airbag

94 - Seat-Front Left

95 - Seat-Front Right

96 - Seat-Rear

97 - Carpet-Rear

98 - Interior-Other

44 - Gas Tank

54 - Undercarriage-Other

81 - Gas Cap/Cover

90 - Frame

91 - Exhaust System https://docs.google.com/forms/d/1DLappepVClPaZMNMC8NihAu11vRxaYRN_qgKsZT-Nr8/edit 8/10

28.

Other:

Check all that apply.

01 - Bent

02 - Broken (Except Glass)

03 - Cut

04 - Dented (Paint Broken)

05 - Chipped (Except Glass)

06 - Cracked (Except Glass)

07 - Gouged

08 - Missing

09 - Scuffed

10 - Interior Stained or Soiled

11 - Punctured

12 - Scratched (Except Glass)

13 - Torn

14 - Dented-Paint/Chrome Not Damaged

18 - Molding/Emblem/Weatherstrip-Damaged

19 - Molding/Emblem/Weatherstrip-Loose, Missing

20 - Glass-Cracked

21 - Glass-Broken

22 - Glass-Chipped

23 - Glass-Scratched

29.

Files submitted:

Additional Documentation & Information

30.

Files submitted:

Please Select All Applicable Damage Type Codes as Referenced in the Above Diagram: *

Picture(s) of Damage (max 5) *

Copy of Carrier's Signed Bill of Lading Noting Damage/Delivery Receipt (or Explanation for Missing BOL) * https://docs.google.com/forms/d/1DLappepVClPaZMNMC8NihAu11vRxaYRN_qgKsZT-Nr8/edit 9/10

31.

32.

Files submitted:

Preferred Dealership / Authorized Body Shop

33.

Mark only one oval.

Yes Skip to question 34

No Skip to question 37

Preferred Dealership / Authorized Body Shop Information

34.

35.

Additional Information (Vehicle needs to be towed, interior of vehicle exposed to the environment, etc...)

Additional Documentation (max 1 file; no additional photos)

Do you have a preferred dealership/authorized body shop for this vehicle? *

Location Name *

Phone Number * https://docs.google.com/forms/d/1DLappepVClPaZMNMC8NihAu11vRxaYRN_qgKsZT-Nr8/edit 10/10

36.

Certification

37.

Check all that apply.

I certify that I have verified that all information provided is accurate and complete, and that all documents, photographs, and attachments are included as necessary.

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Email Address *

Certification *

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