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Corners Coppell-CS100309o P PIMI Loss Control Joann Sherwood P0. Box 27087 Phone: 888 -PHX -LOSS Phoenix Loss Control, Inc. Denver. CO 80227 March 9, 2010 City of Coppell Attn: Damage Claim Dept./ Risk Management 816 S. Coppell Rd. P.O. Box 9478 Coppell, TX 75019 RE: Your file number: UNKNOWN Our file number: DALN1002002 Date of Damage: 2 -5 -10 Location of Damage: 200 S. MacArthur Blvd., Coppell, TX Amount Owed: $5,870.74 ATTN: Damage Claims Dept., Our company is handling the recovery interests of Time Warner /Dallas. Your company (sub- contractor) damaged Time Warner's .875 cable while doing work at the above location. Based on the information provided by the market, we have found you to be liable for this damage to Time Warner's facilities. Please forward any information that may dispute our findings, or payment in full, within 21 days of receipt of this correspondence. If you are insured, you may consider turning this matter over to your insurance carrier, otherwise payment is due within 21 days of this letter and invoice. Visa /MasterCard /Discover credit cards are accepted with a 2% processing fee. Checks, Certified Money Orders, or Cashier's checks should be made payable to Phoenix Loss Control, Inc. and sent to P.O. Box 27087, Denver, CO. 80227 Please reference our file number at the top on your check. If you have questions or require additional information, please contact me at the number listed above, during normal business hours. Sincerely, Joann Sherwood Claims Manager Phoenix Loss Control, Inc. Office: 888 -PHX -LOSS Ext. 11 Fax: 866 - 864 -7508 email: joann_ sherwood @phoenixiosscontrol.com Invoice No. DALN1002002 P.O. Box 27087 Denver, CO 80227 Office 888 -PHX -LOSS /E-mail: joann_ sherwood @phoenixlosscontrol.com INVOICE - Responsible party Name City of Coppell Address 816 S. Coppell Rd, P.O. Box 9478 City Coppell State TX ZIP 75019 Phone 972 -462 -5150 Fa x 972 -462 -5199 8 2 2 1.5 1.5 2 800 800 2 30 1 Date 3/8/2010 Client Time Warner Rep Joann Sherwood Unit Price $0.65 $14.04 $7.80 $29.25 $44.69 $14.74 $0.65 $5.01 $7.80 $18.20 $71.87 feet .875 cable .875 temp connectors heat shrink hour Maintenance Tech hour Tech Vehicle Perm .875 Connectors Feet .875 Cable Feet Underground Cable Placement Perm heat shrink feet road bore coordinator /vehicle Please Remit Payment within 21 days of this notice. Thank You! Pow Outage /Loss of Use for 1.5 hour(s) SubTotal Nayment Details Check - Include Claim # on your check VISA/MC /Discover -2% Process Fee Name on Card City State Zip Card# Expire Date Security# L oss of Use TOTAL Office Use Only Damage discovered 2 -5 -10 at 200 S. MacArthur Blvd., Coppell, TX - no locates requested TOTAL $5.20 $28.08 $15.60 $43.88 $67.04 $29.48 $520.00 $4,008.00 $15.60 $546.00 $71.87 350.74 $520.00 Please send check to: Phoenix Loss Control, Inc. P.O. Box 27087, Denver, CO 80227 P - Loss Control ( io Damage Claim Report Client: Time Warner PAGE 1 - Claim# DALN1002002 Technician Name 8 Radio # Barry Brown Tech ID: Supervisor Damage Date: 2/5/2010 Time of Loss 10:00 am AM or PM Phoenix Investigator: Date called about damage: 2/5/2010 Time called 1:09 pm AM or PM Date Arrived at Damage: 2/5/2010 Mileage to /from Damage 36 Time Arrived: 3:45 AM or PM Time Left: 4:00 m Ann or PM Damage Location Address: 200 S MacArthur Blvd SPOC /Coordinator: David C. Beal Jr. Discovery Date: 2/5/2010 Supervisor Name: Barry Brown City: Coppell State: TX Zip: 75019 Office Name: Dallas - Supervisor Number: 972 - 877 -7380 Detail of Loss /Damage: CATV facilities damaged during replacement of a fire hydrant. Statement of Damager (include person's name): None Comments made at scene (name & phone no. of person making comment): None. Damage Loc Type: 2 Activity Type: 13 Damage By: 2 Facility Type: 4 1 —Apt Complex 9 — Street 1 — CAN Exc. — Sewer Exc 1 —Auger 9 — Motor Veh. 1 —Aerial Cable 9 -Pole 2 — Curb 10 — Other _ 2 — Culvert Exc. 10 — Irrigation 2 — Backhoe 10 — Shovel 2 — Aerial Fiber 10- Utility Vault 3 — Driveway 3 — Fence Exc. 11 — Street Exc 3 — Boring 11 —Tractor 3 — Aerial Service — Farm 4 — Fire 12 — Telephone 4 — Crawler 12 — Trencher 4 — Buried Cable 5 — Housing Dev. 5 — Gas Exc. 13 — Water Exc 5 — Dozer 13 — N/A 5 — Buried Fiber 6 — Industrial Dev. 6 — Landscaping 14 — Unknown 1 6 — Dump Truck 14 — Unknown 6 — Buried Service 7 — Residence 7 — Motor Vehicle 5 — Other_ 17 — Farm Equip 15 — Other:_ 7 — Other 8 — Sidewalk 8 — Power Exc. 18 — Grader 8 — Pedestal /Closure /AP Box DAMAGER INFORMATION Contact Name & No: Michael or Debbie mill this Address ® Insurance Company: Policy #: Bill this Address ❑ Company Name: City of Coppell Name: Address: 816 S. Coppell Road, P.O. Box 9478 Address: City: Coppell State: TX Zip: 75019 City: State: Zip: Tele. No: (972 ) 462 -5150 or Fax (972) 462 -5199 Tele. No: ( ) Locate Ticket # none found Dig Start Date & Time: Police Dept or Hazmat: Witness Statement (put add'I witness information on separate page ): Officer Name: Name Report #: Address: City/State: Tele. No.: ) Company Tele. No: ( ) Locate Company Bill this Address ❑ Locate Detail: 7 Name: 1 —Yes, Accurate 6 — Incomplete Locates Address: 2 — Yes, Inaccurate/ Comcast 7 — No Locate Requested City /State: Zip: 3 — Yes, Inaccurate/ Contractor 8 — Premature Dig Telephone #: ( ) 4 —Yes, Locates Removed 9 — Records Error Locate Co Claim #: 5 — Yes, Expired Ticket/Locates Print Info: System ❑ MDU ❑ New Build ❑ No Print ❑ Markings: Paint ❑ Flags ❑ Locates Were Done By: Cable Co ❑ Phone Co. ❑ Gas Co. F Public Works F1 Pnwer C.n F 10 —other _no locates Stakes ❑ Othar 1avnlninl PAGE 2 - DAMAGE ADDRESS 200 S MacArthur Blvd, Coppell, TX 75019 Aerial / Underground Cable Information: Cable Size: Trunk No. of Fibers Depth Damaged: at Damage: Damaged Exposed: ® Yes ❑ No Pole Replaced? Yes ❑ No Cable Strung: Pole to Pole ❑ or to Building ❑ Replacement Footage: 800 ft. The Crosses Cable: (choose the best description) ❑ or Parallels ® the Street ® Highway ❑ Alley ❑ Height of Vehicle: Feet Inches I Height of Attachment: Feet Inches Materials: Materials Form Attached? Yes ❑ No ❑ Complete ALL Materials, Labor, Vehicle, Contractor Cast= Documentation Description — note if materials are used for temp or perm Item # QTY Unit Cost Temporary Repair .875 Trunk Cable 5 ft. Temporary Repair .875 Connector 2 Temporary Repair Heat Shrink 2 Permanent Repair Requested .875 Trunk Cable 800 Permanent Repair Requested .875 Connectors 2 Permanent Repair Requested Permanent Repair Requested IStreet Heat Shrink Bores re q. 2 Subscribers Affected: 145 Duration of Outage (hrs): UNKNOWN Labor Costs - (Time Must Match Employee Timesheets) Date Name of Tech, Supervisor, Manager Position/Title (line tech, maintenance tech, supervisor, etc.) Hours Supervisor Hours Reg OT 2/5/10 Tech Maintenance Tech 1 1/2 Work Vehicles Dispatched Date Vehicle Type Hours Date Vehicle Type Hours 2/5/10 Bucket 11/2 Contractor Information Name jAddress Tele. No. ( )- Voucher /Contractor Bills — Documentation Must Be Available Name Description Amount Miscellaneous Charges - Documentation Must Be Attached Name Description Amount Signature of Damage Investigator: David C. Beal Jr. Date of Investigation: 2/5/10 Map Map 121 mot 5 TAW 129 - 1001 AV 205 wpp- v - 1 209 i 4 4 W-. 208 X13 _ y& A r . if i 5 � s -�,_ 212 217 { 2 0 5 0 0 Feet 221 Streets Building PhotoFeb2009 Streets ❑Building NRed: Band-1 City Limit FUTURE ❑Green: Band-2 City Limit NBlue: Band-3 County Line Parcel m ■County Line Parcel Rail Road Park Page 1 of 1 http : / /gis.coppelltx.gov /aspnet_ client/ ESRI/ WebADF /PrintTaskLayoutTemplates /default.h... 3/10/2010