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HomeMy WebLinkAboutContract 52404-FP1 City Secretary 52404 -FP1 Contract No. FORTWORTH., Date Received Aug 7,2020 NOTICE OF PROJECT COMPLETION (Developer Projects) The Transportation and Public Works Department upon the recommendation of the Project Manager has accepted the following project as complete: Project Name: Ridgeview Farms Phase 6 City Project No.: 101428 Improvement Type(s): Water ® Sewer Original Contract Price: $685,931.80 Amount of Approved Change Order(s): $5,880.00 Revised Contract Amount: Total Cost of Work Complete: $691,811.80 Ake 6Let4f Aug 2020 Albert Grantges(Aug 6,20 13:43CDT) g Contractor Date Contract Manager Title Burnsco Construction, Inc. Company Name C44rl.—.'0. 8 Aug 6,2020 Charles D.Bevins(Aug 6,202015:45 CDT) Project Inspector Date Date FR�HI2016:36 CDT) Aug 6,2020 Project Manager Date zmy/6 zm* Aug 2020 Laurie Lewis(Aug 6,202016:44 CDT) g f CFA Manager Date 75ar4,guNg6&)o E Dana Burghdoff( g6,202 6:57 CDT) Aug 6,2020 Asst. City Manager Date OFFICIAL RECORD CITY SECRETARY Page 1 of 2 FT. WORTH, TX Notice of Project Completion Project Name: Ridgeview Farms Phase 6 City Project No.: 101428 City's Attachments Final Pay Estimate Change Order(s): ® Yes ❑ N/A Pipe Report: ® Yes ❑ N/A Contractor's Attachments Affidavit of Bills Paid Consent of Surety Statement of Contract Time Contract Time: 180 CD Days Charged: 235 Work Start Date: 7/8/2019 Work Complete Date: 6/1/2020 Page 2of2 FORT WORTH CITY OF FORT WORTH FINAL PAYMENT REQUEST Contract Name RIDGEVIEW FARMS PHASE 6 Contract Limits Project Type WATER&SEWER City Project Numbers 101428 DOE Number 1428 Estimate Number 1 Payment Number 1 For Period Ending 6/1/2020 CD City Secretary Contract Number Contract Time BLED Contract Date 6/3/2019 Days Charged to Date 235 Project Manager NA Contract is 100.00 Complete Contractor BURNSCO CONSTRUCTION,INC. 6331 SOUTHWEST BLVD FORT WORTH, TX 76132 Inspectors CORDOVA / BEVINS Thursday,August 6,2020 Page 1 of 5 City Project Numbers 101428 DOE Number 1428 Contract Name RIDGEVIEW FARMS PHASE 6 Estimate Number 1 Contract Limits Payment Number 1 Project Type WATER&SEWER For Period Ending 6/1/2020 Project Funding UNIT 1:WATER IMPROVEMENTS Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total --------------------------------------- 1 8"WATER PIPE 5858 LF $21.00 $123,018.00 5858 $123,018.00 2 8"PVC WATER PIPE CSS BACKFILL 20 LF $30.00 $600.00 20 $600.00 3 FIRE HYDRANT ASSEMBLY W/6"GATE 9 EA $3,700.00 $33,300.00 9 $33,300.00 VALVE&BOX 4 16"X 8"TAPPING SLEEVE&VALVE 1 EA $4,600.00 $4,600.00 1 $4,600.00 5 4"-12"WATER ABANDONMENT PLUG 3 EA $20.00 $60.00 3 $60.00 6 DUCTILE IRON WATER FITTINGS 3.3 TN $4,365.00 $14,404.50 33 $144,045.00 W/RESTRAINT 7 CONNECTION TO EXISTING 4"-12"WATER 2 EA $800.00 $1,600.00 2 $1,600.00 MAIN 8 8"GATE VALVE(CO#2) 22 EA $1,280.00 $28,160.00 22 $28,160.00 9 1"WATER SERVICE 129 EA $840.00 $108,360.00 129 $108,360.00 10 1 1/2"PRIVATE WATER SERVICE(CO#1) 3 EA $1,200.00 $3,600.00 3 $3,600.00 11 TRENCH SAFETY 5878 LF $0.10 $587.80 5878 $587.80 12 16"WATERLINE LOWERING 75 LF $178.00 $13,350.00 75 $13,350.00 Sub-Total of Previous Unit $331,640.30 $461,280.80 UNIT IL-SANITARY SEWER Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total --------------------------------------- 1 4'MANHOLE 28 EA $2,225.00 $62,300.00 28 $62,300.00 2 4'DROP MANHOLE 1 EA $3,500.00 $3,500.00 1 $3,500.00 3 8"WATER PIPE(DR-18 FOR SANITARY SEWER 51 LF $28.00 $1,428.00 51 $1,428.00 USE) 4 8"SEWER PIPE 5173 LF $25.60 $132,428.80 5713 $146,252.80 5 8"SEWER PIPE,CSS BACKFIL L 398 LF $36.00 $14,328.00 398 $14,328.00 6 8"SEWER CARRIER PIPE 153 LF $26.00 $3,978.00 153 $3,978.00 7 4'EXTRA DEPTH MANHOLE 53 VF $145.00 $7,685.00 53 $7,685.00 8 4"SEWER SERVICE 128 EA $610.00 $78,080.00 128 $78,080.00 9 CONNECT TO EXISTING MH 1 EA $1,400.00 $1,400.00 1 $1,400.00 10 4'MANHOLE ON EXISTING 18"SEWER 1 EA $4,600.00 $4,600.00 1 $4,600.00 11 20"CASING BY OPEN CUT 153 LF $118.60 $18,145.80 153 $18,145.80 12 TRENCH SAFETY 9269 LF $0.60 $5,561.40 9269 $5,561.40 Thursday,August 6,2020 Page 2 of 5 City Project Numbers 101428 DOE Number 1428 Contract Name RIDGEVIEW FARMS PHASE 6 Estimate Number 1 Contract Limits Payment Number 1 Project Type WATER&SEWER For Period Ending 6/1/2020 Project Funding 13 MANHOLE VACUUM TESTING 30 EA $110.00 $3,300.00 30 $3,300.00 14 POST-CCTV INSPECTION 5775 LF $1.40 $8,085.00 5775 $8,085.00 15 TRENCH WATER STOPS 13 SF $300.00 $3,900.00 13 $3,900.00 16 REMOVE SIDEWALK 80 SF $1.80 $144.00 80 $144.00 17 REMOVE CONC PVMT 13 SY $15.50 $201.50 13 $201.50 18 4"CONC SIDEWALK 80 SF $7.70 $616.00 80 $616.00 19 6"CONC PVMT 13 SY $130.00 $1,690.00 13 $1,690.00 20 EPDXY MANHOLE LINER(CO#1) 40 VF $220.00 $8,800.00 40 $8,800.00 -------------------------------------- Sub-Total of Previous Unit $360,171.50 $373,995.50 Thursday,August 6,2020 Page 3 of 5 City Project Numbers 101428 DOE Number 1428 Contract Name RIDGEVIEW FARMS PHASE 6 Estimate Number 1 Contract Limits Payment Number 1 Project Type WATER&SEWER For Period Ending 6/1/2020 Project Funding Contract Information Summary Original Contract Amount $685,931.80 Chanize Orders Change Order Number 1 $4,600.00 Change Order Number 2 $1,280.00 Total Contract Price $691,811.80 Total Cost of Work Completed $835,276.30 Less %Retained $0.00 Net Earned $691,811.80 Earned This Period $691,811.80 Retainage This Period $0.00 Less Liquidated Damages Days @ /Day $0.00 LessPavement Deficiency $0.00 Less Penalty $0.00 Less Previous Payment $0.00 Plus Material on Hand Less 15% $0.00 Balance Due This Payment $691,811.80 Thursday,August 6,2020 Page 4 of 5 City Project Numbers 101428 DOE Number 1428 Contract Name RIDGEVIEW FARMS PHASE 6 Estimate Number 1 Contract Limits Payment Number 1 Project Type WATER&SEWER For Period Ending 6/1/2020 Project Funding Project Manager NA City Secretary Contract Number Inspectors CORDOVA / BEVINS Contract Date 6/3/2019 Contractor BURNSCO CONSTRUCTION,INC. Contract Time 80 CD 6331 SOUTHWEST BLVD Days Charged to Date 235 CD FORT WORTH, TX 76132 Contract is .000000 Complete CITY OF FORT WORTH SUMMARY OF CHARGES Line Fund Account Center Amount Gross Retainage Net Funded -------------------------------------- Total Cost of Work Completed $835,276.30 Less %Retained $0.00 Net Earned $691,811.80 Earned This Period $691,811.80 Retainage This Period $0.00 Less Liquidated Damages 0 Days @ $0.00 /Day $0.00 LessPavement Deficiency $0.00 Less Penalty $0.00 Less Previous Payment $0.00 Plus Material on Hand Less 15% $0.00 Balance Due This Payment $691,811.80 Thursday,August 6,2020 Page 5 of 5 ƒ a § 2 / \ q / 2 2 m@ ¢ c o 0 o s + / § / -i @ ) 3 / % m \ \ m / > / / CL \ , G , �-i 2 \ / m q ^ % q ® � ^ / M r % ; ) % G o e \ a 2 2 / > \ $ / 2 ; § < / = 2 m \ 2 2 a * \ % ; g 2 % > .. / o g > w z § > > \ \ / § = - ; 3 } \ # # ; 0ZM ) m ; ® % o ° k 2 QM { m & 2 § K ® < _ e o c > 2 2 m : § \ \ > / Cc / \ •. g g _ ¥ , \ 2 / & a ± \ d o \ / } ) c \ \� ° O 3 } / \ \ $ 2 e 2 / / M ° m _ _ ot \ § ® , 2 Pi 4 k } / eg e , _ ® 3 (D °2 19 g 00 $ t / _ \ o / % q 5 m w o > — G E _ ƒ % \} 3 % � g f\ \ g § / gw Cl) m � o 0 ^ ° / \ z / Q2 � ~ ° ® E \ q { / o § § ¢ p = j zm ( _ � 00 § q ) 2 ° } 0 \CD2 ° )> CD / G � � _ m /» CD § 72e » a { §; - ƒ ° / \{ < } o ® +aa � J > ja < % / ; / (D { 2 } } k \ z m Qwco E / q f m 2 § y 3 = = z = p a } _ ? \ @ 2 \ \ ! » J e ` & / w \ ® § \ j ^ * \ - - \_ \ § qc % { ° \ 2 § § aG 0 2 ° 5 } } \ / \ \ _ 9j \ ( y »eg \ m oe & g , _ S CD � A 3 ) \ } \ gCD ~ 0 $ \ § o 9 � z } \ RK2 \ # o % / _ c » } § 65 ggm - _ co ] m > ° \ \ - -10 - * m § a 3 c \\ / _ » % # \ \ma » 9 3 2 ( & /CD q2 / \ \ , mm g \ } % ) mM � J o a $. 2m � \ \ 4 ) k CD ( mCD \( CD ( / n 73 9 z = m > 2 { §~ \ CD0 \ m z _ } - \ m » n E } ( a £ - \ ® z0 lb 3 \ § \ � \ m \ _ 220 / CD CD ƒ § § / g q \ 2 2 2 $ = o 0 0 2 § \ z ) } \ / \ m k / / / o = » > m m # m m # ? a \ § m q n q % / n o 2 2 m Q g 2 i / w J = G w / I I / \ w CA 0 0 > z 2 = \ `0 ) ( 2 ) / Q / / / / j \ ) C Q G M i § / / m n _ CO £ ± o w + z k / 9 \ / # # [ m \ Ko 2 \ , CD 02 » / 2 CA o A. 0 cm \ \ j La / / .. ` / \ _ k 2 e 7 o K >/ j m c » t 7 $ < \ \ \ 2 CD° 2 w mco co @ @ \- - - o \ , 2 ° 00 \ } ° \ Q / ee \ FF / 2 J 00 .. .. / % 0 $ 5_ _ e 66 co -4 /< > » % $ \ / } n ) o § / > \ @_ m e { 0 e w = \ o 22 _ i ] 2 } m 70 � \ 2 © qz _ fm P � 0m g ( \ } 7 ) S < T (ID Q ƒ $ « \ \ \ ( \ 2 4 / / > 22 \ § CD z 0 z ( o. o \ ) # ( A m § \ \ e } a � n ) \ \ § ?) � } \ CD z 2 ) ( 2J o _ » 4j ? } \ 0 ) o o ! z }) CD 0 3 m } \ _ < - CD § \ z F0 w z = > $ 5 ~ 3 ] �� - ® m o> - ) G & , \ ) y CDg &_ d CD §( z }§ CD ; =G \ (M ! D] ( ) 2 $ ° & ED m \ 0 } j / j / 2 z n } }CD � \ m p / m \ g c m \ 0 6 \ m \ m 7 4 \ k \ fl-m. z � \\ > / c, � FORT WORTH TRANSPORTATION AND PUBLIC WORKS PIPE REPORT FOR: PROJECT NAME: Ridgeview Farms PH 6 PROJECT NUMBER: 101428 DOE NUMBER: N/A WATER PIPE LAID SIZE TYPE OF PIPE LF 8" PVC C-900 5878 LF 6"inch PVC 36 LF FIRE HYDRANTS: 9 VALVES(16" OR LARGER) PIPE ABANDONED SIZE TYPE OF PIPE LF DENSITIES: NEW SERVICES: 1" Copper 3760 LF SEWER PIPE LAID SIZE TYPE OF PIPE LF 8"inch SDR-26 PVC 5724 LF 8"inch DR 18 51 LF PIPE ABANDONED SIZE TYPE OF PIPE LF N/A DENSITIES: NEW SERVICES: 4" inch PVC 2410 LF TRANSPORTATION AND PUBLIC WORKS ONThe City of Fort Worth• 1000 Throckmorton Street•Fort Worth,TX 76012-6311 (817)392-7941 •Fax: (817)392-7845 FORTWORTH. TRANSPORTATION AND PUBLIC WORKS August 3, 2020 Burnsco Construction, Inc. 6331 Southwest Blvd Benbrook,TX 76132 RE: Acceptance Letter Project Name: Ridgeview Farms PH6 Water&Sanitary Sewer Project Type: Development City Project No.: 101428 To Whom It May Concern: On June 1, 2020 a final inspection was made on the subject project. There were no punch list items identified at that time. The final inspection indicates that the work meets the City of Fort Worth specifications and is therefore accepted by the City. The warranty period will start on June 1,2020, which is the date of the final inspection and will extend of two(2)years in accordance with the Contract Documents. If you have any questions concerning this letter of acceptance, please feel free to contact me at (817) 392-8424. Sincerely, FRED EHIA(Aug 6,202016:36 CDT) Fred Ehia, P.E., Project Manager Cc: Doug Bevins, Inspector Ron Cordova, Inspection Supervisor Gary Deyon,Senior Inspector Victor Tornero, Program Manager John Andersen, Kimley Horn, Consultant Burnsco Construction Inc., Contractor 287/156 Partners, L.P., Developer File E-Mail: Douglas W.Wiersig, P.E., PhD., Director,TPW Chris Harder, P.E.,Assistant Director,Water Richard Martinez,Assistant Director,TPW Wendy Chi-Babulal, P.E.,Water Marisa Conlin,Traffic Engineering Tony Sholola, P.E., Water Allen Hall, Superintendent,TPW Richard Zavala, Director, PARD John Robert Carman, P.E., Director,Water David Creek,Assistant Director, PARD Rev.9/15/16 AFFIDAVIT STATE OF TEXAS COUNTY OF TARRANT Before me, the undersigned authority, a notary public in the state and county aforesaid, on this day personally appeared Ab Grantges, Contract Mgr, Of Burnsco Construction, known to me to be a credible person, who being by me duly sworn, upon his oath deposed and said; That all persons, firms, associations, corporations, or other organizations furnishing labor and/or materials have been paid in full; That the wage scale established by the City Council in the City of Fort Worth has been paid in full; That there are no claims pending for personal injury and/or property damages; On Contract described as; Ridgeview Farms Phase 6 -Water, Sanitary Sewer and Storm Drain BY b , kb Grantge , Contract Manager Subscribed and sworn before me on this date 9th of August, 2020. 6.1� 1, CESILIA CANALES Notary Public = Notary 14#131652996 Tarrant County Texas q�r My Commission Expires EOFS� July 2a, 2022 CONSENT OF OWNER ❑ SURETY COMPANY ARCHITECT ❑ TO FINAL PAYMENT SORE RY CTOR ❑ Conforms with the American Institute of OTHER Architects,AIA Document G707 Bond No 022223035 PROJECT: (name, addreSS)Ridgeview Farms Phase 6-Water, Sanitary Sewer and Drainage Improvements Fort Worth TX TO Owner) 287I156 PARTNERS, L.P.AND THE CITY OF FORT ARCHITECT'S PROJECT NO: WORTH CONTRACT FOR: 8750 N.Central Expressway,Suite 1735 Ridgeview Farms Phase 6-Water, Sanitary Sewer and Drainage Improvements Dahas Tx 75231 —J CONTRACT DATE: CONTRACTOR: BURNSCO CONSTRUCTION, INC. In accordance with the provisions of the Contract between the Owner and the Contractor as indicated above,the there insert name and address of Surety Company) LIBERTY MUTUAL INSURANCE COMPANY 175 Berkeley Street Boston MA 02116 , SURETY COMPANY on bond of Thera insert na,ne and address of Contractor) BURNSCO CONSTRUCTION, INC. 6331 Southwest Boulevard Benbrook TX 76132 , CONTRACTOR, hereby approves of the final payment to the Contractor, and agrees that final payment to the Contractor shall not relieve the Surety Company of any of its obligations to (here insert name and address of Owner) 2871156 PARTNERS, L.P.AND THE CITY OF FORT WORTH 8750 N. Central Expressway;Suite 1735 Dallas TX 75231 , OWNER, as set forth in the said Surety Company's bond, IN WITNESS,WHEREOF, the Surety Company has hereunto set its hand this 4th day of August, 2020 LIBERTY MUTUAL INSURANCE COMPANY Surety Company Attest: �4 L,:C, (Seal): Signatdre of Authorized Representative Sophinie Hunter Attorney-in-Fact Title NOTE: This form is to be used as a companion document to AIA DOCUMENT G706, CONTRACTOR'S AFFIDAVIT OF PAYMENT OF DEBTS AND CLAIMS, Current Edition ©NE PAGE This Power of Attorney limits the acts of those named herein,and they have no authority to bind the Company except in the manner and to the extent herein stated. .ilberti, Liberty Mutual Insurance Company The Ohio Casualty Insurance Company Certificate Na 8200743 IVILitual, West American Insurance Company SURETY POWER OF ATTORNEY KNOWN ALL PERSONS BY THESE PRESENTS:That The Ohio Casualty Insurance Company is a corporation duly organized under the laws of the State of New Hampshire,that Liberty Mutual Insurance Company is a corporation duly organized under the laws of the State of Massachusetts,and West American Insurance Company is a corporation duly arganized under the laws of the State of Indiana(herein collectively called the"Companies"),pursuant to and by authority herein set forth,does hereby name,constitute and appoint, Robbi Morales,Don E.Cornell,Sophinie Hunter,Tina McEwan,Tonic Petranek,Ricardo J_Reyna, Joshua Saunders, Kelly A.Westbrook all of the city of Dallas state of TX each individually if there be more than one named,its true and lawful attorney-in-fact to make, execute,seal,acknowledge and deliver,for and on its behalf as surety and as its act and deed,any and all undertakings,bonds,recognizances and other surety obligations,in pursuance of these presents and shall be as binding upon the Companies as if they have been duly signed by the president and attested by the secretary of the Companies in their own proper persons. IN WITNESS WHEREOF,this Power of Attorney has been subscribed by an authorized officer or official of the Companies and the corporate seals of tho Companies have been affixed thereto this 19th day of March 2019 Liberty Mutual Insurance Company P4%NSURq P'11 INS& SNSU4 Q The Ohio Casualty Insurance Company J RPO j 2�0 T 0 cJ=GORPORgr� �'P L�RppRgrF yn West American Insurance Company [0 1912 y o 0 1919 1991 % a r b fi a' %2� �w o 4 0 �//t yT9/ cn �jk Ss9CHH50 aD O h'hAM45�� if �N ,sti1�)' m a3 ezz * s�Ma*Nh`'aD By, c Cn David M.Carey,Assistant Secretary � _ -0 State of PENNSYLVANIA 0 County of MONTGOMERY ss o N On this 19th day of March 2019 before me personally appeared David M.Carey,who acknowledged himself to be the Assistant Secretary of Liberty Mutual Insurance o o Company,The Ohio Casualty Company,and West American Insurance Company,and that he,as such,being authorized so to do,execute the foregoing instrument for the purposes— } therein contained by signing on behalf of the corporations by himself as a duly authorized officer. w 5 IN WITNESS WHEREOF,I have hereunto subscribed my name and affixed my notarial seal at King of Prussia,Pennsylvania,on the day and year first above written. a l _ p C)COMMONWEALTH Of PENNSYLVANIA — o .... Notaria€Seal- -_-.-...... /� ¢� i TFr k Pa t€la,Notary Pu61ic U �� Upper%4n,on Twp. Man;�cmery County By +�-�✓ t- My Cu nm=ssioo Exp€:'as March 28.2021 BreSa Pastetia,Notary Public `Alms.Perms}aria Ass iAmn ci NeVirias O (0 �� _ Co o._ Insurance Company,and West American Insurance to ` m m This Power of Attorney is made and executed pursuant to and by authority of the following icy-laws and Authorizations of The Ohio Casualty Insurance Company, Liberty Mutual 67 � Company which resolutions are now in full force and effect reading as follows: p � ar ARTICLE IV—OFFICERS:Section 12.Power ofAttorney. o ro Any officer or other official of the Corporation authorized for that purpose in writing by the Chairman or the President, and subject to such limitation as the Chairman or the President may prescribe,shall appoint such attorneys-in-fact,as may be necessary to act in behalf of the Corporation to make,execute,seal,acknowledge and deliver as surety a o M C any and all undertakings,bonds,recognizances and other surety obligations.Such attorneys-in-fact,subject to the limitations set forth in their respective powers of attorney,shall N have full power to bind the Corporation by their signature and execution of any such instruments and to attach thereto the seal of the Corporation.When so executed,such "0O o instruments shall be as binding as if signed b the President and attested to b the Secretary.An N Z c�.1 g 9 Y y ry. y power or authority granted So any representative or attorney-in-fact under the co provisions of this article may be revoked at any time by the Board,the Chairman,the President or by the officer or officers granting such power or authority. °O ARTICLE XIII—Execution of Contracts:Section 5.Surety Bonds and Undertakings. o 0 Any officer of the Company authorized for that purpose in writing by the chairman or the president,and subject to such limitations as the chairman or the president may prescribe, F-- shall appoint such attorneys-in-fact,as may be necessary to act in behalf of the Company to make,execute,seal,acknowledge and deliver as surety any and all undertakings, bonds,recognizances and other surety obligations.Such attorneys-in-fact subject to the limitations set forth in their respective powers of attorney,shall have full power to bind the Company by their signature and execution of any such instruments and to attach thereto the seal of the Company.When so executed such instruments shall be as binding as if signed by the president and attested by the secretary. Certificate of Designation—The President of the Company,acting pursuant to the Bylaws of the Company,authorizes David M.Carey,Assistant Secretary to appoint such attorneys-in- fact as may be necessary to act on behalf of the Company to make,execute,seal,acknowledge and deliver as surety any and all undertakings,bonds,recognizances and other surety obligations. Authorization—By unanimous consent of the Company's Board of Directors,the Company consents that facsimile or mechanically reproduced signature of any assistant secretary of the Company,wherever appearing upon a certified copy of any power of attorney issued by the Company in connection with surety bonds,shall be valid and binding upon the Company with the same force and effect as though manually affixed, I,Renee C.Llewellyn,the undersigned,Assistant Secretary,The Ohio Casualty Insurance Company,Liberty Mutual Insurance Company,and West American Insurance Company do hereby certify that the original power of attorney of which the foregoing is a full,true and correct copy of the Power of Attorney executed by said Companies,is in full force and effect and has not been revoked. IN TESTIMONY WHEREOF,I have hereunto set my hand and affixed the seals of said Companies this 4th -day of August , 2020 SNSUq VS1 INS& tNSU P`oRP okq?�oy n �J 2`aRPo gr�o9n UP2 oRPaRgr�y� 1912 o M 5 a fi o y1919� o 1991 0 cAll �j>gsS9 CH155e�.�L O yAM 5 a� � �NOInN0. D� By. �h * 1 �y1 * �Na s�� 1 a Renee C.Llewellyn,Assistant Serxetary LMS-12873 LMIC OCIC WAIC Multi Co 082D1e Liberty Mutudi. SURETY TEXAS TEXAS IMPORTANT NOTICE AVISO IMPORTANTE To obtain information or make a complaint: Para obtener informacion o para someter una queja: You may call toll-free for information or to Usted puede llamar a] numero de telefono gratis make a complaint at para informacion o para someter una queja al 1-877-751-2640 1-877-751-2640 You may also write to: Usted tambien puede escribir a: 2200 Renaissance Blvd., Ste. 400 2200 Renaissance Blvd., Ste. 400 King of Prussia, PA 19406-2755 King of Prussia, PA 19406-2755 You may contact the Texas Department of Puede comunicarse con el Departamento de Insurance to obtain information on companies, Seguros de Texas para obtener informacion coverages, rights or complaints at acerca de companias, coberturas, derechos o 1-800-252-3439 quejas al 1-800-252-3439 You may write the Texas Department of Insurance Puede escribir al Departamento de Seguros Consumer Protection (I 1 I-IA) de Texas Consumer Protection (I 11-IA) P. O. Box 149091 P. O. Box 149091 Austin, TX 7871.4-9091 Austin, TX 78714-9091 FAX: (512) 490-1007 FAX# (512)490-1007 Web: http://www.tdi.texas.gov Web: http://www.tdi.texas.gov E-mail: ConsumerProtectiongtdi.texas.gov E-mail: Cons umerProtectiongtdi.texas_gov PREMIUM OR CLAIM DISPUTES: DISPUTAS SOBRE PRIMAS O RECLAMOS: Should you have a dispute concerning your Si tiena una disputa concerniente a su prima o a premium or about a claim you should first un reclamo, debe comunicarse con el agente o contact the agent or call 1-800-843-6446. primero. Si no se resuelve la disputa, puede If the dispute is not resolved, you may contact the entonces comunicarse con el departamento (TDI) Texas Department of Insurance. ATTACH THIS NOTICE TO YOUR UNA ESTE AVISO A SU POLIZA: POLICY-. This notice is for information only and does not Este aviso es solo para proposito de informacion become a part or condition of the attached y no se convierte en parte o condicion del document. documento adjunto. NP 70 68 09 01 LMS-15292 10115