North Carolina Department Of Transportation Active Claim Resolution Form Page 3
Download a blank fillable North Carolina Department Of Transportation Active Claim Resolution Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete North Carolina Department Of Transportation Active Claim Resolution Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4Claim Resolution Form
Requests for Additional Compensation:
(Applicable section(s) to be filled out by Resident Engineer)
104-3
Alterations of Plans or Details of Construction
1.
Has the Contractor submitted all information as required by the Subarticle?
Yes
No
2.
Did the contractor notify the Resident Engineer in writing prior to performing the work?
Yes
No Date: ______________
3.
Did the Department advise the Contractor in accordance with the Subarticle?
Yes
No
N/A
4.
Did the Contractor submit his claim within 120 days after completion of the work?
Yes
No
5.
Has the Contractor submitted records as required by Subarticle 104-8(B)?
Yes
No
6.
Has the Character of performing the work materially changed?
Yes
No
Please explain: _____________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
7.
Has the cost of performing the work changed?
Yes
No
Please explain: __________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
8.
Amount of additional compensation recommended $___________________________ Please explain:_____________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
104-4
Suspension of Work
1.
(a) Was the temporary suspension ordered by the Resident Engineer in writing?
Yes
No If no, go to (b). If yes:
What are the dates of authorized temporary suspension: __________________________through_______________________
Did the contractor notify the Resident Engineer in writing within 7 days of the suspension of his intent to file a claim for
additional compensation?
Yes
No Date of Notification: _____________________
Has the Contractor submitted his written request for adjustment in compensation with cost records, supporting data and
information within 14 calendar days of the receipt of the notice to resume work?
Yes
No Go to 2.
(b) What was the alleged delay? ____________________________________________________________________________
What are the dates of Contractor's alleged suspension: __________________________through________________________
Did the contractor notify the Resident Engineer in writing of his intent to file a claim for additional compensation due to the
alleged suspension?
Yes
No Date of Notification: ______________________________
Has the Contractor submitted his written request for adjustment in compensation with cost records, supporting data and
information within 14 calendar days after the last day of the period during which he contends the alleged suspension of work
should have occurred?
Yes
No Go to 2.
2.
Has the Contractor submitted records as required by Subarticle 104-8(C)?
Yes
No (See #3 below)
Has the Contractor kept records in accordance with Article 109-3 (Force Account Work)?
Yes
No
Did the Contractor give the Resident Engineer the opportunity to review the records?
Yes
No
Has the Contractor submitted additional documentation as requested by the Resident Engineer?
Yes
No
N/A
Has the Contractor submitted cost records on a weekly basis within 7 days?
Yes
No
3.
Was the temporary suspension or alleged suspension more than 24 hours in duration?
Yes
No
4.
Amount of additional compensation recommended $___________________________ Please explain:_____________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Form ACRF-2 (5-28-15)
Page 3 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form E-585s - Incentive Claim For Refund State And County Sales And Use Taxes Form - North Carolina Department Of Revenue - North Carolina
Financial
Form Dma-5125b - Medicaid Transportation Suspension Notice - North Carolina Department Of Social Services
Legal
Related Categories
Parent category: Business