Attachment D.pdf
PDF 77 KB Posted
- Attached to
- PAVEMENT MARKING-DISTRICT 4 State and local contract opportunity
- Solicitation number
- 5400026515
- Issued by
- Richland County, South Carolina
About this file
This is a Damage Claim Form (Form 2062) issued by the South Carolina Department of Transportation for processing vehicle damage claims related to road conditions or incidents on state roadways. The form establishes procedures for claimants to report and seek compensation for damages sustained to vehicles and personal injuries resulting from incidents on SCDOT-maintained routes. Claimants must submit claims within one year from the date of the incident. Required documentation includes a completed form with typed or clearly printed information, a copy of the vehicle registration, two repair estimates or a paid invoice, notarized signature from the vehicle owner as listed on the registration, and photographs of the damage. For pothole-related claims specifically, claimants should provide photos of the pothole itself and surrounding area to assist investigators in locating the incident site.
The form requires claimants to provide detailed incident information including the date, time, location, route, nearest intersecting road, county, vehicle details, and a comprehensive description of the incident and damage or injury sustained. Claimants must identify any witnesses and indicate whether the incident was reported to law enforcement. The affidavit section requires notarization before a notary public and contains a statement affirming that the claim is true and that no compensation has been received from other sources. SCDOT headquarters uses the lower section of the form for internal processing, including claim number assignment, approval or disapproval determination, approved amount, and date received documentation. The form does not specify claim limits or compensation amounts, leaving those determinations to SCDOT's review and approval process.
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Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| Attachment A.pdf | ||
| Solicitation.pdf | ||
| Attachment H.xlsx | XLSX spreadsheet | |
| Attachment F.pdf | ||
| Attachment G.xlsx | XLSX spreadsheet | |
| Attachment I.xlsx | XLSX spreadsheet | |
| Attachment E.pdf | ||
| Certification.pdf | ||
| Attachment C.pdf | ||
| Attachment B.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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