47QMCA23R0076 Attachment 18 - DIT Claim Form Template (Leasing).pdf
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- Attached to
- 2024 Star of Life Ambulances
- Solicitation number
- 47QMCA23R0076
- Issued by
-
GSA Federal Acquisition Service
About this file
This document is a template for submitting damage in transit claims to the General Services Administration (GSA) Federal Acquisition Service related to vehicles leased through GSA Fleet. The template collects information about vehicle details including brand, model, VIN and damage codes; delivery and receipt information; parties involved including names, addresses, phone numbers and email addresses; damage descriptions and pictures; preferred repair shops; and a certification. Claims are to be submitted using this template to GSA's vehicle claims email for processing.
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Text version
8/5/2021 GSA Fleet - Damage in Transit Claim Reporting Form https://docs.google.com/forms/d/1zVJcfQMimHMADyWp7nKkhIP6J_7KbzoO-7grmaEfCuo/edit 1/13
1. Email *
GSA Zonal Point of Contact (POC) Information
2.
3.
4.
5.
GSA Fleet - 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
GSA Zonal POC - Name *
GSA Zonal POC - Title *
GSA Zonal POC - Email Address *
GSA Zonal POC - Phone Number * Please enter a valid 10-digit phone number, including dashes, in the following format: 123-456-7890 https://docs.google.com/forms/d/1zVJcfQMimHMADyWp7nKkhIP6J_7KbzoO-7grmaEfCuo/edit 2/13
6.
Mark only one oval.
Not Applicable / Not sure
Marshaller/Consignee POC Information
7.
8.
9.
10.
Your Information
GSA Zonal POC - Zone *
Marshaller/Consignee POC - Name *
Marshaller/Consignee POC - GACA Email Address *
Marshaller/Consignee POC - Business Email Address *
Marshaller/Consignee POC - Phone Number * Please enter a valid 10-digit phone number, including dashes, in the following format: 123-456-7890 https://docs.google.com/forms/d/1zVJcfQMimHMADyWp7nKkhIP6J_7KbzoO-7grmaEfCuo/edit 3/13
11.
Mark only one oval.
Other:
Same as Marshaller/Consignee POC
12.
Mark only one oval.
Other:
Same as Marshaller/Consignee POC
13.
Mark only one oval.
Other:
Same as Marshaller/Consignee POC
14.
Mark only one oval.
Other:
Same as Marshaller/Consignee POC
Your Name *
Position/Title *
What is the name of your company? *
Your Email Address * https://docs.google.com/forms/d/1zVJcfQMimHMADyWp7nKkhIP6J_7KbzoO-7grmaEfCuo/edit 4/13
15.
Mark only one oval.
Other:
Same as Marshaller/Consignee POC
Vehicle Receipt Information
16.
Mark only one oval.
Other:
Same as Marshaller/Consignee POC
17.
Mark only one oval.
Other:
Same as Marshaller/Consignee POC
18.
Mark only one oval.
Other:
Same as Marshaller/Consignee POC
Your Phone Number * Please enter a valid 10-digit phone number, including dashes, in the following format: 123-456-7890
Location Vehicle Received - Address *
Person Who Received the Vehicle - Name *
Person Who Received the Vehicle - Email Address * https://docs.google.com/forms/d/1zVJcfQMimHMADyWp7nKkhIP6J_7KbzoO-7grmaEfCuo/edit 5/13
19.
Mark only one oval.
Other:
Same as Marshaller/Consignee POC
Vehicle Information
20.
21.
22.
Delivery Information
23.
Example: January 7, 2019
24.
Mark only one oval.
Yes
No
Person Who Received the Vehicle - Phone Number * Please enter a valid 10-digit phone number, including dashes, in the following format: 123-456-7890
Vehicle Brand/Model *
RPN / Order Number *
Full VIN *
Date Vehicle Received *
Was the vehicle delivered during normal business hours? * https://docs.google.com/forms/d/1zVJcfQMimHMADyWp7nKkhIP6J_7KbzoO-7grmaEfCuo/edit 6/13
25.
26.
27.
Damage Information
28.
Example: January 7, 2019
29.
Current Location of Vehicle - Address *
Transportation Company - Company Name *
Transportation Company - Driver's Name *
Date Damaged was Noticed *
Description of Damage * https://docs.google.com/forms/d/1zVJcfQMimHMADyWp7nKkhIP6J_7KbzoO-7grmaEfCuo/edit 7/13
GSA Fleet Damage Code Reference Sheet https://docs.google.com/forms/d/1zVJcfQMimHMADyWp7nKkhIP6J_7KbzoO-7grmaEfCuo/edit 8/13
30.
Check all that apply.
01 - Antenna/Antenna Base
02 - Battery/Box
03 - Bumper/Cover/Ext-Front
05 - Bumper Guard/Strip-Front
09 - Door-Right Cargo
10 - Door-Left Front
11 - Door-Left Rear
12 - Door-Right Front
13 - Door-Right Rear
14 - Fender-Left Front
15 - Quarter Panel/Pickup Box-Left
16 - Fender-Right Front
17 - Quarter Panel/Pickup Box-Right
18 - Front Floor Mats
19 - Rear Floor Mats
20 - Glass Windshield
22 - Grille
23 - Accessory Bag/Box
24 - Headlight/Cover/Turn Signal
25 - Lamps-Fog/Driving/Spot
27-Hood
30 - Mirror-Outside Left
31 - Mirror-Outside Right
35 - Rocker Panel/Outer Sill-Left
36 - Rocker Panel-Outside Sill-Right
37 - Roof
38 - Running Board/Step-Left
39 - Running Board/Step-Right
40 - Spare Tire/Wheel
42 - Splash Panel/Spoiler-Front
44 - Gas Tank
52 - Deck Lid/Tailgate/Hatchback
53 - Sunroof/T-Top
54 - Undercarriage-Other
55 - Cargo Area/Other
Please select all applicable damage AREA codes as referenced in the above diagram:
https://docs.google.com/forms/d/1zVJcfQMimHMADyWp7nKkhIP6J_7KbzoO-7grmaEfCuo/edit 9/13
Other:
56 - Vinyl/Convertible Top/Tonneau Cover
57 - Wheel Covers/Caps/Rings
59 - Wipers, all
64 - Spoiler/Deflector-Rear
65 - Luggage Rack (Strips)/Drip Rail
68 - Carpet-Front
69 - Center Post Right
70 - Center Post-Left
71 - Corner Post
76 - Right Rear Tire
77 - Right Rear Wheel/Rim
78 - Right Front Tire
79 - Right Front Wheel/Rim
80 - Cowl
81 - Gas Cap/Cover
85 - Communication/GPS Unit
90 - Frame
91 - Exhaust System
93 - Steering Wheel/Airbag
94 - Seat-Front Left
95 - Seat-Front Right
96 - Seat-Rear
97 - Carpet-Rear
98 - Interior-Other
99 - Engine Compartment-Other https://docs.google.com/forms/d/1zVJcfQMimHMADyWp7nKkhIP6J_7KbzoO-7grmaEfCuo/edit 10/13
31.
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
Bill of Lading (BOL)
32.
Mark only one oval.
Yes Skip to question 33
No Skip to question 34
Please select all Applicable damage TYPE codes as referenced in the above diagram:
Was a copy of Carrier's Signed Bill of Lading (BOL) noting damage/delivery receipt provided? * https://docs.google.com/forms/d/1zVJcfQMimHMADyWp7nKkhIP6J_7KbzoO-7grmaEfCuo/edit 11/13
Upload Bill of Lading (BOL)
33.
Files submitted:
Skip to question 35
Explanation for Missing Bill of Lading (BOL)
34.
Attachments & Additional Information
35.
Files submitted:
36.
Please upload the copy of Carrier's Signed Bill of Lading (BOL) noting damage/delivery receipt. *
Please provide an explanation for the missing BOL: *
Picture(s) of Damages (max 5). **Reminder: Image file names must include RPN and last 8 characters of VIN *
Additional Information Additional Information (Vehicle needs to be towed, interior of vehicle exposed to the environment, etc...)
https://docs.google.com/forms/d/1zVJcfQMimHMADyWp7nKkhIP6J_7KbzoO-7grmaEfCuo/edit 12/13
37.
Files submitted:
Preferred Dealership / Authorized Body Shop
38.
Mark only one oval.
Yes Skip to question 39
No Skip to question 42
Preferred Dealership / Authorized Body Shop Information
39.
40.
41.
Certification
42.
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.
Additional Documentation (max 1 file; no additional photos)
Do you have a preferred dealership/authorized body shop for this vehicle? *
Location Name *
Phone Number *
Email Address *
Certification * https://docs.google.com/forms/d/1zVJcfQMimHMADyWp7nKkhIP6J_7KbzoO-7grmaEfCuo/edit 13/13
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