WA9701-CL060309LAWSUIT/CLAIMS AGAINST THE CITY TRANSMITTAL FORM
DATE::
DISTRIBUTION LIST:
Jim Witt, City Manager
Bob Hager, City Attorney
Vivyon Bowman, Director of HR
Texas Municipal League
Lawsuit File (original/copy)
COMMENTS:
\\TWN_CTR\USERS\Kwilkers\Claim Forms\Suit Transmittal Form doc
Revised 8/19/94
CLAIM NOTICE
City Secretary
City of Coppell
P.O. Box 9478
Coppell, TX 75019
(972) 304-3673 (FAX)
(For Office Use Only)_
CLAIM NO. F'~c~gg>g, ~9:;/-~ FILED IN
MY OFFICE IrI~S THE _ afl D~A.Y OF
ADMINISTRATIVE SECRETARY
This is my notice of claim against the City of Coppell. The circumstances giving rise to this claim
are as follows:
1. Theinjuryordamageoccurredonthe_/~?a~flayof ~ ,20~i~,at
approximately o'clock , at the specific location of_
, in Coppell, Texas.
2. The damage or injury occurred in the following manner:
The full extent of my damages and/or injuries are as follows (be specific - attach estimates,
bills, etc. ff available):
4. The amount of damages claimed is $
(Please Print)
Claimant L~o~
~ ( ~/~,~ Phone(____)
Area Code
Address City~State~Zip
(Also list previous address if less than 6 months)
I do swear the above is tree and correct.
s~gned Date
The notification shall be filed within six (6) months of the date o£ injury or damage or, in the case of death, within six (6) months of
the date of death. The failure to so notify the City within the time and manner specified shall exonerate, excuse and exempt the City
from any liability whatsoever. (Artide 11, Section 11.09 o£ the Home Rule Charter Damage Suits)
Revised 06/03/02
verlTon
CMR CLAIMS DEPARTMENT
P,O. BOX 60770
OKLAHOMA CITY, OK 73146-0770
1-866-887-4066
*****NOTICE OF CLAIM*****
Date: 3/3/2006
CERTIFIED MAIL~ RETURN RECEIPT REQUESTED
To:
CITY OF COPPELL
CITY SECRETARY LIBBY BALL
255 PARKWAY BLVD
P O BOX 9478
COPPELL, TX 75019
CERTIFIED MAIL# 91 7108 2133 3931 4328 9900
RE: Damage to Verizon Property
Verizon Claim No.: TXPR060564
Date of Damage/Discovery: 1/18/2006
Location of damage: DENTON TAP & SOUTHWESTERN NEAR DAIRY
QUEEN,LEWISVlLLE,TX
Amount of Damage: Undetermined
Dear Sir/Madam:
Please be advised that Verizon Facilities sustained damage as a result of the
negligent acts or omissions by employees or agents of CITY OF COPPELL
(J.T. DRESNER, INC.).
Investigation has revealed that on or about 1/18/2006 employees or agents of
CITY OF COPPELL (J.T. DRESNER, 1NC.), DAMAGED 100 PAIR BURIED
CABLE WITH HEAVY EQUIPMENT WHILE PLACING 16" WATER LINE
FOR CITY in area of DENTON TAP & SOUTHWESTERN NEAR DAIRY
QUEEN, LEWISVILLE, X.
REQUEST FOR GOVERNMENTAL NOTICE FORM
If your Governmental Entity requires the completion of its own form to complete proper
notice, please forward a copy to the address listed above. Every good faith effod has
been made to identify the proper office and address to perfect our notice. Please forward
to your attorney, if misdirected, to contact us. Matters herein stated are alleged on
information and belief this pleader believes to be true. If there is insurance to cover this
matter, kindly advise as to the name of the insurance company, its address and the claim
number assigned. If you have any questions, or need additional information, please
contact~.//P'~ J my.~.Sista nt, Michele Givens at 1-800-321-4158 ext 8273.
CMR Claims DEPT NOTAR~ ~(~ ~**~0'~ ~
Commission Expires W'/.~ z ~ e ...............
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