Attachment D.pdf
PDF 122 KB Posted
- Attached to
- ON-CALL TREE REMOVAL - ORANGEBURG
- Solicitation number
- 5400029881
- 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. The form is used to document incidents involving vehicle damage or personal injury that may be attributed to road conditions, such as potholes or other SCDOT-related hazards. Claimants must submit the form within one year of the incident date and provide comprehensive information including the damaged vehicle details, incident location, date and time, claimed amounts for both personal injury and property damage, and descriptions of the incident with all parties involved. Supporting documentation requirements include a copy of the vehicle registration, two repair estimates or a paid invoice, photographs of the physical damage and the incident location, and a notarized affidavit certifying the claim's accuracy.
The claim must be signed by the vehicle owner as named on the vehicle registration and notarized before submission. The form contains a section for SCDOT headquarters use only, where claims are reviewed for approval or disapproval with a claim number and received date recorded. While this form is presented alongside a contract opportunity for on-call tree removal services in Orangeburg, South Carolina, the damage claim form itself serves as an administrative tool for the public to seek reimbursement for road-related damages rather than as a procurement document.
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Other files
| File | Type | Posted |
|---|---|---|
| Notice Regarding Award.pdf | ||
| Attachment F.pdf | ||
| Solicitation.pdf | ||
| Attachment E.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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