Attachment G (Third-Party).pdf
PDF 236 KB Posted
- Attached to
- ON CALL FULL DEPTH PATCHING-SPARTANBURG
- Solicitation number
- 5400030222
- Issued by
- Spartanburg County, South Carolina
About this file
This document is a Damage Claim Form (Third-Party) issued by the South Carolina Department of Transportation. The form is designed to document and process claims for vehicle damage or personal injury incidents involving third parties. The form requires claimants to provide detailed information including the claimant's name, Federal Employer Identification Number (FEIN), contact information, address, phone number, email, damaged vehicle details (make, model, license plate, and state registration), and company or organization information. All applicable fields must be completed, and claimants must be properly notarized. The form serves as the official documentation mechanism for initiating damage claims with the state transportation department.
To substantiate claims, claimants are required to submit supporting documentation alongside the completed form, including two repair estimates or a paid invoice to establish the amount being claimed. In cases involving personal injury or non-vehicle damage, additional documentation or receipts must be provided. The form specifies that all approved fields must be completed and that proper notarization of the claimant information is mandatory before submission. This standardized form facilitates the processing and tracking of third-party damage claims against the South Carolina Department of Transportation.
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Other files
| File | Type | Posted |
|---|---|---|
| SOLICITATION.pdf | ||
| Attachment E Damage Claim.pdf | ||
| Attachment F Damage Notice.pdf | ||
| Attachment D.pdf |
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Text version
Attachment G - Damage Claim Form (Third-Party)
FC11!12062
R8V011ZJIA
SOUTH CAROLINA DEPARTMENT OF TRANSPORTATION
DAMAGE CLAIM FORM
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Personally ,1ppe.all!d � me , who, upon o.ath, s,ays th.at the .above aatnant(I) Nne claim is true .and jU5t, .and th.at he/she hzi not ..-eceived compensation from other sources for dam.ages cl.aimed.
Sworn to before me this day of 20_
NolaryP!dctt>r (SUie) Prfnll!d name<•I or e1am;inq,1
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DO NOTWRITE BELOW THIS UNE. FOR ICDOT USE ONLY.
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