Scdot Claim Form PDF Details

Navigating the complexities of filing a claim for damages with the South Carolina Department of Transportation (SCDOT) requires a detailed understanding of the SCDOT Claim Form, officially known as Form 2062. Revised in January 2014, this form serves as a critical step for individuals seeking reimbursement for damages that resulted from incidents involving SCDOT's purview—be it a personal vehicle, property damage, or personal injury. It mandates clear stipulations: the form must be typed or printed, the claimant(s) must own the vehicle in question if the claim involves vehicular damage, and all claims must be substantiated with two repair estimates or a paid invoice to clarify the amount being claimed. For personal injury or non-vehicular claims, appropriate documentation of losses is required. Completeness is a must, as all fields on the form need to be filled, and claimant signatures notarized, ensuring the process's integrity. Furthermore, the form asks for detailed information about the claimant, the incident, and any law enforcement reports, creating a comprehensive picture of the claim. Each claim is evaluated on its own merits, putting emphasis on the importance of accuracy and completeness in the submission.

QuestionAnswer
Form NameScdot Claim Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesscdot claims department, scdot claims form, scdot form 2062, sc claim dot form

Form Preview Example

Form 2062

Rev 01/2014

SOUTH CAROLINA DEPARTMENT OF TRANSPORTATION

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

 

 

 

Damaged Vehicle

 

 

(_____) _____- _______

(_____) ____ - _______

(_____) ______ - _______

Make_________________________

___________________

Home Phone

Work Phone

Cell Phone

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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Step # 2 in submitting scdot form sample

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