Form 2062 - Damage Claim Form - South Carolina Department Of Transportation

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SOUTH CAROLINA DEPARTMENT OF TRANSPORTATION
Form 2062
DAMAGE CLAIM FORM
Rev 01/2014
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
Tag Number & State
Model_________________________
_______________________________________________
_______________________________ Agent(s)_________________________________
Insurance Company(s)
Policy Number(s)
Phone(s) (____) ______-________ (____) _____-_______
__________________
_____________ AM or PM
$_____________________________
$_______________________________
Date of Incident
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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