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2. Department of Customer Services (DCS) Identification Number:

   In order to receive an identification number, please email Department of Customer Services (DCS) dcsmail@rcoc.org OR call 877-858-4804 ***MAKE SURE TO INCLUDE THE LOCATION (ROAD, NEAREST MAJOR CROSSROAD AND COMMUNITY) OF THE INCIDENT. ***

   
   

4. 
6. DAMAGE CLAIM FORM for the Road Commission for Oakland County, MICHIGAN

   Information must be provided completely and accurately in order for a claim to be considered. A claim against RCOC for alleged monetary damages can be only considered for that portion not otherwise covered by insurance.

8. Important information:
   NOTE: Please provide the following if available: copy of police report; copy of written estimates of damages if applicable; bills or proof of payment for any damages allegedly suffered but NOT covered by insurance; photographs or any other documentation which could help substantiate your claim against the Road Commission for Oakland County (RCOC).
10. Claim processing information:
    Please be aware that under state governmental immunity laws MCL 691.1402 and MCL 691.1403 you must show that the RCOC failed to maintain the actual roadbed of the highway in reasonable repair to prove a highway defect claim. You also must show that the RCOC knew of the condition and had an opportunity to repair it, or that the condition existed for more than 30 days. The RCOC will only consider damages not covered by your insurance company. Once your claim is received it will be assigned within approximately 30 days to the RCOC third party administrator for review and determination (determination can take up to 90 days):
12. I have read the claim processing information*

    1. Check Here
14. CONTACT MDOT (for damage claims on state roads)
    Michigan Department of Transportation (MDOT) Claim Process and Form

    For claims on roads beginning with I, M or US (I-75, I-96, I-696, M-1/Woodward, M-5, M-10/Lodge, M-15, M-24/Lapeer, M-59/Highland, US-24/Telegraph) contact Michigan Department of Transportation (MDOT) at 248-451-0001.

18. **We recommend that you use Chrome, Firefox, or Internet Explorer 10 or higher to complete this form.**
20. First Name*
21. Last Name*
22. Area Code*
23. Phone number*
25. Address*
27. City*
28. State*
29. Zip Code*
31. Email address*
33. Date of incident:*
34. Time of incident:*
35. Amount of claim $:*
39. Location of incident (name of road):*
    If road or bridge claim, list the road name, direction of travel, closest crossroads, county. If a building, list address. If a RCOC vehicle, provide description and license plate number. For claims on roads beginning with I, M or US, (I-75, I-96, I-696, M-1/Woodward, M-5, M-10/Lodge, M-15, M-24/Lapeer, M-59/Highland, US-24/Telegraph) contact Michigan Department of Transportation (MDOT) at 248-451-0001.
41. Nearest Major Crossroad*
43. City, Village or Township where incident occurred*
45. Injury/damage description:*
    Describe your injury, loss or damage in detail. Attached additional pages if necessary. Please note, for mailboxes, the RCOC will either replace with a similar size mailbox and post or reimburse resident up to $25.00. For a mailbox/ post replacement, please call 877-858-4804 or email dcsmail@rcoc.org
47. Claim value:*
    How did you determine the value of your claim? Describe in detail and attach copies of receipts or estimates. MAILBOX claims will only be reimbursed up to $25. R.C.O.C. can replace with similar size mailbox and post. To request replacement, call 877-858-4804 or email dcsmail@rcoc.org
49. Explain why the RCOC is responsible:*
    Describe alleged highway/road or building defect or alleged negligent operation of RCOC vehicle.
51. Explain why you are not at fault:*
    Explain why you are not at fault and why you could not prevent the loss.
53. How long has the condition (subject of your claim) been in existence? *
    Additional documentation of the condition can be attached at the end of the form.
55. Have you filed other claims against the Road Commission for Oakland County? (check one)*

    1. YES
    2. NO

    If yes, attach relevant information.
56. Have you filed a claim or received reimbursement for all or any portion of this claim from another source? (check one)*

    1. YES
    2. NO
58. Did your incident occur in a construction zone? (check one)*

    1. YES
    2. NO
59. Do you have any other potential source of reimbursement (such as vehicle insurance) for all or a portion of this claim? (check one)*

    1. YES
    2. NO

    If yes, attach explanation.
61. Witnesses:*
    Provide names, addresses and phone numbers for any witnesses.
63. Other information:
    Other information which you feel should be considered.
65. I understand that once a claim is received it will be assigned within approximately 30 days to the RCOC third party administrator for review and determination (determination can take up to an additional 90 days). *

    1. Check here
69. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
71. Electronic Signature*
73. Date and time of signature.*
    Date and time of signature.

    Date and time of signature.
75. Additional Document:
77. Additional Document:
79. Additional Document:
Leave This Blank:


81. 1. Receive an email copy of this form.
82. Email address

    This field is not part of the form submission.

83. Submit

* indicates a required field