Attachment G.pdf
PDF 77 KB Posted
- Attached to
- ON-CALL GUARDRAIL SPARTANBURG
- Solicitation number
- 5400029927
- Issued by
- Spartanburg County, South Carolina
About this file
This is the South Carolina Department of Transportation Form 2062 Damage Claim Form, revised August 5, 2022, used to process vehicle damage claims resulting from incidents on state roads and highways. The form establishes five mandatory criteria that must be met for claim processing: all fields must be typed or clearly printed, the vehicle owner named on the vehicle registration must be the claimant, a copy of vehicle registration must accompany the submission, two repair estimates or a paid invoice must be provided, and the claimant's signature must be notarized. Claimants have one year from the date of incident to file a claim and are required to provide detailed information including the damaged vehicle specifications, date and time of incident, location and route information, description of the incident and type of damage, and contact information for any witnesses.
The form requires claimants to report amounts claimed for both personal injury and property damage and requests photographic documentation of the damage. For pothole-related incidents specifically, claimants should provide photos of the pothole itself, photos showing the pothole with surrounding area context to aid investigator location efforts, and additional photos even if the pothole has been filled by the time documentation occurs. The completed claim form must include a notarized affidavit 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. SCDOT headquarters personnel review submissions and indicate approval or disapproval with the assigned claim number, approved amount, and date of determination on the form.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment F- Work Zone.pdf | ||
| Attachment D.pdf | ||
| AMENDMENT 1.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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