DAMAGE CLAIM FORM.pdf
PDF 122 KB Posted
- Attached to
- ON-CALL TREE REMOVAL SPARTANBURG
- Solicitation number
- 5400028325
- Issued by
- Spartanburg County, South Carolina
About this file
The document is a Damage Claim Form issued by the South Carolina Department of Transportation (SCDOT) for individuals seeking compensation for vehicle damage caused by road conditions or incidents. The form provides a standardized process for claimants to submit damage claims, with specific requirements including a one-year filing deadline from the date of the incident. Claimants must provide detailed information about the damage, including vehicle details, incident location, description of the damage, and supporting documentation such as vehicle registration, repair estimates or paid invoices, and photographic evidence.
The claim form requires comprehensive documentation, including contact information, precise incident details, and a notarized affidavit affirming the claim's truthfulness. Claimants must submit two repair estimates or a paid invoice, a copy of vehicle registration, and optional photographic evidence of the damage or pothole. The form includes sections for personal injury and property damage claims, with space to document witnesses and law enforcement involvement. SCDOT reserves the right to review and approve or disapprove claims based on the submitted information and adherence to the specified criteria.
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Other files
| File | Type | Posted |
|---|---|---|
| NON-COMPLIANCE NOTICE.pdf | ||
| DAMAGE TO SCDOT PROPERTY.pdf | ||
| Solicitation.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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