WA9701-CL060309 (2)LAWSUIT/CLAIMS AGAINST THE CITY TRANSMITTAL FORM
DATE::
DISTRIBUTION LIST:
d-'-'"~Jim Witt, City Manager
Bob Hager, City Attorney
Vivyon Bowman, Director of HR
Texas Municipal League
Lawsuit File (original/copy)
COMMENTS:
\\TWN_CTR\USERS\Kwdkers\Claim Fom~s\Sutt Transmittal Form.doc
Revised 8/19/94
CLAIM NOTICE
City Secretary
City of Coppell
P.O. Box 9478
Coppell, TX 75019
(972) 304-3673 flAX)
(For Office Use Only)
CLAIM NO~ ~FILED IN
MY OFFICE THIS THE _ c~ . DAy OF
P~O-rcJ~ ,20~O _Go
--' ADMINIsTRATiVE SECRETARY
This is my notice of claim against the City of Coppell. The circumstances giving rise to this claim
are as follows:
The injury or damage occurred on the 6/ day of ~o~.-v-~
approximately o'clock , at the~pecific
,20¢Y-~., at
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. if available):
4. The amount of damages claimed is $_
(Please primo
Claimant //H otc/-/ '~.t-)g'~..~
Phone
Area Code
Address City/State/Zip
(Also list previous address if less than 6 months)
I do swear the above is true and correct.
Signed Date
The notification shall be filed within six (6) months of the date of 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. (Article I 1, Section 11.09 of the Home Rule Charter - Damage Suits)
Revised 06/03/02
verlTo
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 9733
RE: Damage to Verizon Property
Verizon Claim No.: TXPR060499
Date of Damage/Discovery: 114/2006
Location of damage: DENTON TAP AND SOUTHWESTERN (COPPELL) AND
BELTLINE (NW CORNER BY DAIRY QUEEN),LEWlSVILLE,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
(SKAGGS CO.).
Investigation has revealed that on or about l/4/2006 employees or agents of CITY
OF COPPELL (SKAGGS CO.) DAMAGED 600 PAIR BURIED CABLE
WHILE BORiNG UNDER DENTON TAP TO PLACE A 16" WATER LINE
FOR CITY OF COPPELL in area of DENTON TAP AND SOUTHWESTERN
(COPPELL) AND BELTLINE (NW CORNER BY DAIRY QUEEN),
LEW1SVILLE, TX.
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 my assistant, Michele Givens at 1-800-321-4158 ext 8273.
si
CMR Claims DEPT
Commission Expires