Attachment D Damage Claim.pdf
PDF 122 KB Posted
- Attached to
- ON CALL BRIDGE REPAIRS PICKENS
- Solicitation number
- 5400026675
- Issued by
- Pickens County, South Carolina
About this file
This is a Damage Claim Form (Form 2062) from the South Carolina Department of Transportation used for processing claims related to vehicle damage allegedly caused by roadway conditions or incidents involving state-maintained infrastructure. The form establishes specific filing requirements and procedures for claimants seeking compensation. Claimants must submit claims within one year of the incident date and provide documentation including typed or legibly printed information, the vehicle owner's signature notarized by a notary public, a copy of vehicle registration, and either two repair estimates or a paid invoice. Supporting photographic evidence is strongly encouraged, particularly for pothole-related damage claims where both close-up and contextual photos of the damaged pothole are requested to aid investigators in locating the incident site.
The form requires claimants to provide detailed incident information including the date, time, location, damaged vehicle specifications, amounts claimed for personal injury and property damage, and witness information. Claims must include an affidavit sworn before a notary public attesting to the truthfulness of the claim and confirming that no other compensation has been received for the damages claimed. The form designates sections for SCDOT headquarters use only, where representatives indicate approval or disapproval status, assigned claim numbers, received dates, and approved or disapproved amounts. This form applies to the On-Call Bridge Repairs contract for Pickens County, South Carolina, establishing the administrative mechanism for damage claims related to transportation infrastructure maintenance and repair activities in that jurisdiction.
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Other files
| File | Type | Posted |
|---|---|---|
| Revised Award Date.pdf | ||
| Notice Regarding Award.pdf | ||
| Solicitation.pdf | ||
| Attachment B Lane closures.pdf | ||
| Attachment C Work Zone.pdf | ||
| Attachment A Certification.pdf | ||
| Attachment E Bridge List.pdf |
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Text version
SOUTH CAROLINA DEPARTMENT OF TRANSPORTATION
Form 2062 DAMAGE CLAIM FORM Rev 08/05/2022
WE ARE UNABLE TO PROCESS CLAIMS THAT DON'T MEET THE CRITERIA OF NUMBERS 1-5 BELOW:
1. Please type or clearly print all applicable fields except where signature is indicated.
2. An owner of the vehicle as named on the vehicle registration must be the person named as the Claimant.
3. A copy of the vehicle registration must be included with the Claim Form.
4. Two repair estimates or a paid invoice must be included.
5. The Claimant's signature must be properly notarized.
6. Pictures of the physical damage are very helpful to your claim. Also, if you hit a pothole, please send (a) a photo of the pothole only if you can safely do so; (b) a photo of the pothole area with some background to aid the investigator in locating where the damage occurred. If the pothole has been filled when you go to take pictures, please still include the suggested photos.
CLAIMANT HAS ONE (1) YEAR FROM DATE OF INCIDENT TO FILE A CLAIM.
Claimant(s)
Contact Person (if claimant is a company of other organization) Email Address
Mailing Address City State Zip
Home Phone
Work Phone
Cell Phone
Damaged Vehicle
Make ______________________
Model ______________________ Tag Number & State
Date of Incident AM or PM
Time of Incident
Amount Claimed for Personal Injury
Amount Claimed for Property Damage
Place of Incident _________________________________________________________________________________________
Route/Road where Incident Occurred __________________________ Nearest Intersecting Road _________________________
In or Near Town County 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 __________________________
Personally appeared before me
STATE OF _______________________ ,
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 ____________ day of ___________________, 20_____.
Printed name of Notary
Signature of Notary
Notary Public for ____________________________ (State) My commission expires ________________________
Printed name(s) of claimant(s)
Signature(s) of claimant(s)
Date
DO NOT WRITE BELOW THIS LINE. FOR HEADQUARTERS USE ONLY.
Other parties involved _______________________________________________________________________________________
Approved ____ Amount $_______
Claim Number Date Received at SCDOT SCDOT Representative Disapproved ____ Date __________
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