Attachment B.pdf

This is a Damage Claim Form from the South Carolina Department of Transportation (SCDOT). The form (Form 2062, Rev 01/2014) is designed for individuals or organizations to file claims for damage to registered vehicles or personal injury incidents involving SCDOT. The form requires detailed information including claimant details, contact information, vehicle information, insurance details, and specific incident information including date, time, location, and description of damages. Two repair estimates or paid invoices must be submitted with the claim form, and all signatures must be notarized.

The form includes fields for documenting claimed amounts for both personal injury and property damage, though specific pricing terms are not predetermined. The form must be completed with a notarized affidavit section where the claimant swears under oath that the claim is true and that no compensation has been received from other sources for the damages claimed. The bottom section is reserved for SCDOT use only, where officials can approve or disapprove the claim and note the approved amount and date.