Attachment D.pdf
PDF 122 KB Posted
- Attached to
- ON-CALL TREE REMOVAL PICKENS State and local contract opportunity
- Solicitation number
- 5400028367
- Issued by
- Pickens County, South Carolina
About this file
The document is a South Carolina Department of Transportation (SCDOT) Damage Claim Form (Form 2062, revised 08/05/2022) used for individuals to file claims for vehicle damage potentially caused by road conditions or state transportation infrastructure issues. The form provides detailed instructions for claim submission, requiring claimants to include specific documentation such as vehicle registration, repair estimates or paid invoices, and notarized signatures. Claimants must file their claim within one year of the incident and provide comprehensive details about the damage, including the location, date, time, and description of the incident.
The form outlines specific requirements for claim processing, including mandatory documentation like two repair estimates, vehicle registration copies, and a notarized affidavit affirming the claim's truthfulness. Claimants are encouraged to provide additional supporting evidence such as photographs of the damage and, in cases of pothole-related incidents, photos of the pothole location. The form includes sections for contact information, vehicle details, incident description, witness information, and a formal affidavit section to be completed in the presence of a notary public. The bottom of the form is reserved for SCDOT headquarters to record claim approval, disapproval, and processing details.
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Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| Notice of Revised Award Posting Date.pdf | ||
| Notice Regarding Award.pdf | ||
| Solicitation 5400028367.pdf | ||
| Attachment E.pdf | ||
| Attachment F.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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