Attachment E.pdf
PDF 77 KB Posted
- Attached to
- ON CALL FENCE REPAIR SPARTANBURG
- Solicitation number
- 5400030036
- 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. The form establishes the standardized process for claimants to report and seek compensation for damages to vehicles resulting from incidents on state-maintained roadways. Claimants must submit completed forms within one year from the date of the incident and must meet five mandatory criteria to proceed: typed or clearly printed responses, claimant verification as the vehicle owner on the registration, a copy of the vehicle registration, two repair estimates or a paid invoice, and a notarized claimant signature. The form collects essential incident information including the date, time, location, route and nearest intersecting road, vehicle details, damage descriptions, personal injury claims, property damage claims, and witness information. Supporting documentation such as photographs of physical damage and pothole conditions (if applicable) are strongly encouraged to facilitate claim investigation.
The form requires claimants to provide contact information, an affidavit sworn before a notary public, and detailed descriptions of the incident and all parties involved. The South Carolina Department of Transportation reviews submitted claims and designates them as approved or disapproved, assigning a claim number and recording the date received. The form includes a section for SCDOT representative use only, where approval or disapproval determinations and approved amounts are documented. There are no specific pricing terms, set-asides, incumbents, or contract renewal options associated with this damage claim form, as it functions as an administrative instrument for processing liability claims rather than as a procurement or service contract.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment D..pdf | ||
| SOLICITATION.pdf | ||
| Attachment F.pdf | ||
| Attachment G.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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