Attachment C.pdf
PDF 89 KB Posted
- Attached to
- PAVEMENT MARKINGS - DISTRICT 4 State and local contract opportunity
- Solicitation number
- 5400020449
- Issued by
- Richland County, South Carolina
About this file
This document is the South Carolina Department of Transportation (SCDOT) Damage Claim Form (Form 2062, Rev. 01/2014), which serves as the official instrument for submitting claims to SCDOT for damages allegedly caused by the department. The form requires comprehensive documentation including claimant information, vehicle details, incident specifics, insurance information, and the nature and amount of claimed damages. Claimants must provide supporting documentation such as two repair estimates or a paid invoice for vehicular damage, or documentation of losses for personal injury or non-vehicular claims. All applicable fields must be completed, and the claimant's signature must be properly notarized through an affidavit attesting that the claim is true and just and that no compensation has been received from other sources for the damages claimed.
The form accommodates claims for both personal injury and property damage, requiring claimants to specify the amount sought for each category. Claimants are required to provide detailed incident descriptions including the cause and type of damage or injury, all parties involved, witness information, and whether the incident was reported to law enforcement. The form includes space for SCDOT personnel to document receipt date, assign a claim number, and render approval or disapproval decisions with the corresponding claim amount and determination date. This standardized form ensures consistency in damage claim documentation and processing across SCDOT's administrative operations.
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Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| Solicitation.pdf | ||
| Attachment E.pdf | ||
| Attachment D.pdf | ||
| Attachment A.pdf | ||
| Attachment B.pdf | ||
| Amendment #1.pdf | ||
| Attachment F.pdf |
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Text version
Form 2062 Rev 01/2014
SOUTH CAROLINA DEPARTMENT OF TRANSPORTATION
DAMAGE CLAIM FORM
INSTRUCTIONS: Please type or print, except where signature is indicated. If this claim is being submitted for damage to a registered vehicle, the owner(s) of the vehicle must be the claimant(s). In addition to the 2062 Claim Form, two repair estimates or a paid invoice must be submitted to substantiate the amount being claimed. In the case of personal injury, or non-vehicular claims, documentation of losses will be required. All applicable fields on this form must be completed. Claimant(s) signature(s) must be properly notarized.
Claimant(s) Federal Emplover Identification Number (FEIN)
Contact Person (If claimant is a company or other organization Email Address
Address (Street, Apartment Number, PO Box) City I State Zip Damaged Vehicle
Make Home Phone Work Phone Cell Phone Tag Number & StateModel
Insurance Company(s)
Date of Incident
Place of Incident
I AM or PM Time of Incident
Route/Road where Incident Occurred
In or Near Town I County
Agent(s)
Policy Number(s) Phone s)< ) - ( )
I �ount Claimed for Personal Injury Amount Claimed for Property Damage
Nearest Intersecting Route/Road
I Reported to law enforcement agency? If so, which one?
Description of incident; including cause and type of damage or injury (and all parties involved):
Witness or Witnesses to Incident (Name, Address, Phone Number)
AFFIDAVIT
COUNTY OF STATE OF
Personally appeared before me , who, upon oath, says that the above Claimant(s) Name claim is true and just, and that he/she has not received compensation from other sources for damages claimed.
Sworn to before me this
Notary Public for
Printed name of notary
My commission expires
Other parties involved day of 20 __
(State) Printed name(s) of claimant(s)
Signature(s) of claimant(s)
Date
DO NOT WRITE BELOW THIS LINE. FOR SCOOT USE ONLY.
- i.
Approved __ Claim Number
Date Received at SCOOT SCOOT Representative Disapproved __
Amount$ Date ·:_
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