ATTACHMENT G.pdf
PDF 148 KB Posted
- Attached to
- CENTER LINE PAINTING DISTRICT 7
- Solicitation number
- 5400019485
- 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 (SCDOT) for processing claims related to vehicle damage, property damage, or personal injury. The form serves as the official instrument for claimants to submit compensation requests to SCDOT. Claimants must complete all applicable fields, provide either two repair estimates or a paid invoice to substantiate vehicle damage claims, and submit documentation of losses for personal injury or non-vehicular claims. The claimant information section requires identification of the vehicle owner (for vehicle damage claims), contact details, and the damaged vehicle specifics including make, model, and tag number. The form also requires documentation of any applicable insurance information, including company name, agent details, and policy numbers.
The claim must include details of the incident location, date, time, and a comprehensive description of the cause and type of damage or injury, along with identification of all parties involved. Claimants must identify any witnesses and indicate whether the incident was reported to law enforcement. All claimant signatures must be properly notarized through an affidavit section completed by a notary public. Upon submission to SCDOT, the form is processed by an SCDOT representative who documents the claim number, receipt date, and provides either approval or disapproval with the awarded amount. No specific contract term, pricing structure, or funding source is detailed within this form, as it functions as a claims processing instrument rather than a procurement document.
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Other files
| File | Type | Posted |
|---|---|---|
| ATTACHMENT A.pdf | ||
| ATTACHMENT D.pdf | ||
| ATTACHMENT E.pdf | ||
| ATTACHMENT H.pdf | ||
| ATTACHMENT B.pdf | ||
| SOLICITATION.pdf | ||
| ATTACHMENT I.pdf | ||
| Amendment One.pdf | ||
| ATTACHMENT C.pdf | ||
| ATTACHMENT F.pdf |
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Text version
Form 2062 SOUTH CAROLINA DEPARTMENT OF TRANSPORTATION Rev 01/2014 DAMAGE CLAIM FORM
INSTRUCTIONS: Please type or print, except where signature is indicated. If this claim is being submitted for damage to a registered vehicle, the owner(s) of the vehicle must be the claimant(s). In addition to the 2062 Claim Form, two repair estimates or a paid invoice must be submitted to substantiate the amount being claimed. In the case of personal injury, or non-vehicular claims, documentation of losses will be required. All applicable fields on this form must be completed. Claimant(s) signature(s) must be properly notarized.
Claimant(s)
Federal Employer Identification Number (FEIN)
Contact Person (If claimant is a company or other organization)
Email Address
Address (Street, Apartment Number, PO Box)
City
State
Zip
Home Phone
Work Phone
Cell Phone
Damaged Vehicle
Make_________________________
Model_________________________
Tag Number & State
Insurance Company(s)
_______________________________ Agent(s)_________________________________
Policy Number(s) Phone(s) (____) ______-________ (____) _____-_______
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 Route/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 __________________________________ STATE OF ________________________________________
Personally appeared before me ____________________________________, 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____.
Notary Public for ___________________________ (State) Printed name(s) of claimant(s)
Printed name of notary Signature(s) of claimant(s)
My commission expires ____________________________ ____________________________ Date
DO NOT WRITE BELOW THIS LINE. FOR SCDOT USE ONLY.
Other parties involved ___________________________________________________________________________________________
_________________ ____________________ _______________________________ Approved _____ Amount $__________ Claim Number Date Received at SCDOT SCDOT Representative Disapproved _____ Date ______________
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