47QMCA23R0076 Attachment 19 - DIT Claim Form Template (Purchasing).pdf
PDF 570 KB Posted
- 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 reporting damage in transit claims related to vehicles delivered under federal contract number 47QMCA23R0076. The template collects information on the vehicle, delivery details, damage noticed, photos and documentation of damage, preferred repair shop, and a certification. Claims are to be submitted to GSA Fleet using this form for vehicles supplied under the referenced solicitation for 2024 Star of Life Ambulances issued by the GSA Federal Acquisition Service. Required information includes claimant name and contact details, consignee name and details, vehicle details like VIN and supplier, delivery date and carrier, damage areas using provided codes, damage types also using codes, pictures of damage, bill of lading or explanation for its absence, and preferred repair shop details if applicable.
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Text version
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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