Attachment E Damage Claim.pdf
PDF 77 KB Posted
- Attached to
- ON CALL FULL DEPTH PATCHING-SPARTANBURG
- Solicitation number
- 5400030222
- Issued by
- Spartanburg 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 conditions or incidents on state-maintained roads. The form establishes the procedures and requirements for claimants to submit damage claims related to incidents occurring in South Carolina, specifically including damages from potholes and other road-related hazards. Claimants have one year from the date of incident to file a claim. Required documentation includes a completed and notarized claim form, vehicle registration copy, two repair estimates or a paid invoice, and photographic evidence of both the vehicle damage and the incident location (such as pothole photographs with surrounding context to aid investigators in locating the damage site).
The form requires claimants to provide detailed information including the damaged vehicle specifications, incident date and time, exact location and route information, amount claimed for personal injury and property damage, witness information, and law enforcement report details if applicable. All applicable fields must be typed or clearly printed, and the claimant named on the form must be the registered vehicle owner. The form includes an affidavit section requiring notarization, wherein the claimant certifies under oath that the claim is accurate and that no compensation has been received from other sources for the damages claimed. SCDOT headquarters uses a designated section at the bottom of the form to record claim number, receipt date, approval or disapproval status, approved amount, and assigned representative information.
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Other files
| File | Type | Posted |
|---|---|---|
| SOLICITATION.pdf | ||
| Attachment G (Third-Party).pdf | ||
| Attachment F Damage Notice.pdf | ||
| Attachment D.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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