ATTACHMENT D.pdf
PDF 122 KB Posted
- Attached to
- ON CALL TREE REMOVAL GREENVILLE
- Solicitation number
- 5400030004
- 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 resulting from road incidents, including pothole damage. The form establishes standardized procedures for claimants to submit claims for vehicle damage and personal injury sustained on South Carolina roadways. Claimants have one year from the date of incident to file a claim and must meet five primary processing criteria: typed or clearly printed submission of all applicable fields, claimant name matching vehicle registration ownership, inclusion of a copy of vehicle registration, submission of two repair estimates or a paid invoice, and a properly notarized claimant signature. The form requires detailed incident information including the damaged vehicle specifications, date and time of incident, precise location and route information, description of the incident and damage type, and witness information.
The claim form requires supporting documentation including photographs of physical damage and, in pothole-related claims, photographic evidence of the pothole itself and the surrounding area to assist investigators in locating the damage site. Claims are processed through SCDOT headquarters, which reviews submissions and issues approval or disapproval decisions with assigned claim numbers and approved payment amounts. The form includes an affidavit section requiring notarization, in which the claimant affirms under oath that the claim is true and just and that no compensation has been received from other sources for the claimed damages. Processing information such as the date received, SCDOT representative responsible for review, and final determination are recorded in the designated headquarters-use section of the form.
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Other files
| File | Type | Posted |
|---|---|---|
| AMENDMENT 1.pdf | ||
| ATTACHMENT G.pdf | ||
| ATTACHMENT F.pdf | ||
| ATTACHMENT E.pdf | ||
| SOLICITATION.pdf | ||
| ATTACHMENT H.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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