ST8502-CL 870327CI~I~ NOTICE
City Secretary, City of Coppell
P.O. Box 478
Coppell, TX 75019
(FOR OFFICE USE)
CLAIM NO. 0 S~ 75 7. / FILED
IN MY OFFICE, THIS THE o~~-
Dear Sir:
This is my notice of claim against the City of Coppell. The
circumstances giving rise to this claim are as follows:
1. The injury or damage occurred on the q~- day of /<~~ ,
19 ~3 at approximately ~/aO o'clock ~/~ , at the specific
location of ~-~0 ~/~' ~c~% ~4m~&~ ~%~ in Coppell, Texas.
2. The d~mage or injury occurred in the following manner:
3. The full extent of my damages and/or injuries are as
follows (be specific; attach estimates, bills, etc., if available):
The amount of damages claimed is $ ~/, ~ ~ ~{n~ ~
PHONE
CITY/STATE ~~/[
(please print)
cLAI l l;
i~DRESS ~-'4o ch~j ~ t~ t~
I DO SWEAR T~E ABOVE IS T~ A~D CORRECT
NOTE:
ARTICLE 6252-19, SECTION 16, V.A.T.S. - NOTICE OF DEATH OR INJOR¥
"Sec. 16. NOTICE REQUIRED-Except where there is actual notice on
the part of the governmental unit that death has occurred or that
the claimant has received some injury, any person making a claim
hereunder shall give notice of the same to the governmental unit
against which such claim is made, reasonably describing the injur~
claimed and the time, manner and place of the incident from which
it arose, within six (6) months from the date of the incident~
INSURED BY ADJUSTER PHONE
SYM
I FRONT LABOR LABOR PARTS SYM LEFT LABOR !LABOR PARTS SYM RIGHT LABOR LABOR PARTS
AMT. HRS. AMT, AMT. HRS. AMT. AMT. fiRS, AMT.
Bumper
Bumper Brkt. Fender, Front Fender, Front
Bumper Gd. Fender Shield Fender Shield
/:~' i Frt. System /. ~'- Fender Mldg. Fender Mldg.
~ Frame Headlamp Headlamp
rCross Member Headlamp Door Headlamp Door
Stabilizer Sealed Beam Sealed Beam
Wheel Cowl Cowl
Hub Cap Windshield Windshield
~ Hub & Drum /~. Door, Front ~ Doort Front
~ Knuckle
~ Knuckle Sup. Door Hinge Door Hinge
Lr. Cont. Arm-Shaft Door Glass Door Glass
~ Vent Glass Vent Glass
Up. Cant. Arm-Shaft /'~ Door Mldgs. ~ ~ Door Mld~.
~ Shock Door Handle Door Handle
[ ~ng Center Post Center Post
~ e Rod Door Rear Door Rear
~ Steering Gear Door Glass Door Glass
~ Steering Wheel Door Mldg. Door Mldg.
__ ~Hor, Ring //. Rocker Panel ~0 ,~cl~ Rocker Panel
J Gravel Shield Rocker Mldg. Rocker Mldg.
__.~ Park. Light Floo~ Floor
~__~ ..... Frame Frame
~ Rad. Grille Dog Leg Dog Leg
'- ~- /~ Qtr. Panel ~ Qtr. Panel
-~--~ .... /~ Qtr. Mldg. ~ y~C Qtr. Mld~.
Qtr. Glass Qtr. Glass
~ Fender, Rear Fender, Rear
~ame Plate Fender Mldg. F ~ ....
Baffle, Side REAR ~[~
- ~ Baffle, Lower Bumper
~ Baffle, Upper Bumper Brkt. ~r~nt ~ Z
...... ~ood Top Lower Panel Headlinin~
~ Hood Hinge Floor lop
T,u. Wa,.
~ Ornament Trunk Light Tube
.... ~Rad. Sup'. Trunk Handle Battery
~Ead. Core Tail ~ight Paint
~Anti Freeze Tail Pipe U~e~coat
___. Rad. Hoses Gas Tank I~.'~ .
Fan Blade ~. Frame ~X~' ~.O AUTHeRIZATIQN FgR REP~IR~
___~ Fan Belt Wheel You are hereby authorized to make the above
~ Water Pump Hub & Drum specified repairs.
Motor Mts. Axle Si~ned
, Clutch Linkage SprJ.~ GROSS PARTS
___
...... ~- NET PARTS
,j PAINT ~TERIAL ~q.
MAKE~_~~, YEAR--STYLE ~;~- MODEL~MILEAOE SALES T~ /'~. /~.
A - Align N-Ne~ OH . Ov~ul S - Straighten or r~ir GRAND TOTAL
...,s coR.o.,.,. Acc,o.T RE~,T PLEAS ~,,EAD
~ ST-, ~11~. 1/1/1~, ''' ' INSTRUCTIONS ON REVERSE SIDE
'*,'* PI..~I~E WHERE
ACCIDENT OCCURRED COUNTY DALLAS crrYo. TOWN CO,T'¥E,T.~., T×. DO NOT WRITE
IN THIS SPACE
IF ACCIDENT WAS OUTSIDE CITY LIMITS, [] [] [] [] OF
INDICATE DISTANCE FROM NEAREST TOWN MILES NORTH S E W CiTY Off TOWN
Z ONS ND.
,~ ROAD ON WHICH 540 Christi Lane at Moore Rd CONSTR.[.~YED SPEED
r.t ACCIREHT OCCURRED ° ZONE [] NO LIMIT LOC
(~. BLOCK NUMBER STREET OR RON) NAME ROUTE NUM~ll CONBTR. [] YES SPEED CUCE
INTERSECTINO STREET ZONE [] NO UMIT
COMPI.L:TE_~ BLOCK NUMBER STREET OR lION) NAME ROUTE NUMBEK
ONE L-NOT AT INTERSECTION. FEET [] [] [] [] OF
SHOW ROL~ OR ROAI~ INTEIISECTI~ NUMBEROO HI.AY. TYPE
NORTH $ E W F UONAN. SNDW !1~ INTENBECTmO STREET ON KEFBNDICE POINT.
,,EOF 87 "'oF
~ ACCIGEm - lB W~K Monday HOUR 9 P.M. '
YOUR VEHICLE
WERE YOU TOWIN6 A TRAILER? IF YES, TYPE
YES OR NO
YEAR TYPE OF UCEDSE
aOGEL 1979 MAKE MERCURY VEDWLE 2 ])t. ~,AT~ 137B?S
FOLIO, CKEV., ETC. BEBAM, PtCNUP, TRUCK, ETC. YEN) STATE NUMROR
- - T~x~ 7575R
OWNED B.PR RROTIPNAME INC. P_O mAe.RnwN)mw~SR5671 Dh11._~ .... ClTYANDSTAI~ Z~P
KELLI ROBINSON ABOVE
0NIVED
NAME MRJL ~RO ¢~Y AND STATE Z~
~R~ER'S 0ATE OF
o uCEDGE 08282355 RmTH 9-3-66 SEX F RaCEWhite 0CCUPATmN STUDENT
DBIVme SPEED YOU WERE DAWING WHEN YOU WHAT WAS THE
EXPERIENCE # 3 FIRST SAW YOU MIRHT HAVE THIS ACCIDENT ~ M.P.H. sIq.'FD UMIT? M.P.H. APPROX. COST TO 8 8 8 2
YEW --J REPAIR YOUR VEHICLE $ '
~ OTHER UNIT - MOTOR VEHICLE, TRAIN, PEOESTRiAN, BICYCLIST, ETC.- INOICATEWHICH ~)T.US ~.I~.NTAL CA~.
~ (COMPt,ETE INFORMATION YOU flare AVAILABLE - IF UNKNOWN, MARK "NOT KNOWN")
lie
/III!11B
m YEAR TYPE OF LICENSE
MODEL. MAKE VEHICLE PLATE
feTAL FORD, CUEV., ETC. SEDAN, PfCKUP, TRUCK, ETC. YEAR STATE NUMBER
~ OWNER
NAME MAIL AOONESS CITY AND STATE ZiP
DRIVER IAPPNOX. COST TO
NAME MAIL. ADDRESS CITY AND STATE ZiP IflEPAIR THIS VEHICLE
DAMAGE TO PROPERTY APPROXIMATE
OTHER THAN VEHICLES COST TO REPAIR S
NAME OBJECT, SHOW OWNERSHIP, AND STATE NATURE OF DAMAGE
NO. 1 (SH~W ONLY PEDESTRIANS OR PERSONS iNJUREb IN YOUR VEHICLE) [] DRIVES [] RIGHT FRONT
NAME ADDRESS [] PASSENGER [] RIGHT REAR
DATE OF [] PEOESTRIAN [] CENTER REAR
~uJ AGE SEX RACE WAS PERSON KILLED? DEATH [] LEFT REAR
~ DESCRIBE INJURY SEAT BELT [] USED [] NOT USED
~ NO. 2 [] onwER [] niRHT FRONT
~ NAME ADDRESS [] PASSENGER [] RIRNT REAR
DATE OF [] PEOESTRIAN [] CENTER REAR
AGE SEX RACE WAS PERSON KILLED? DEATH [] lEFT REAR
DESCRIRE INJURY SEAT BELT []USED [] NOT USED
STATE BRIEFLY WHAT HAPPENED (IF 8PACE 18 INSUFFICIENT CONTINUE ON ANOTHER PAGE)
LTN~AR~]) CONSTRUCTION CAUSING VEHICLE TO ])]TOP OFF INTO CONCRETE AN]) STEEL
S?I~S ])AMAGING SI])E OF CAR AN]) FRONT.
VER'S SleNATURE ~T[ OF R~eNT 3- 2 5 - 8 7
IM~ORTANT! CO!
IUIRED INSURANCE INFO~RMATION ON OTHER SIDE