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Home My WebLink AboutContract 53508-FP1City Secretary 53508 -FP1 Contract No. FORTWORTHo May 4, 2021 Date The Transportation and Public Works Department upon the recommendation of the Project Manager has accepted the following project as complete: Project Name: NORTH QUARTER 35 City Project No.: 102360 Improvement Type(s) Original Contract Price: NOTICE OF PROJECT COMPLETION (Developer Projects) Water � Sewer 0 Amount of Appro�ed Change Order(s): Revised Contract Amount: Total Cost of Work Complete: ��e � a�e Contractor SYB Construction Company, Inc. Title Project Manager Company Name �iN-�.,.Cl �� Dennis Rodgers (May 4, 20211324 CDT) Project Inspector ��G� �foC�res Mltch Holmes (May 4, 2021 1422 CDT) Project Manager 9�cie- sc�Ce-tt- M��Ce� Janie Scarlett Morales (May 4, 202114:30 CDT) CFA Manager Dqvr� Su�cil��loff Dana Burghdoff . 1ay 4, 202114:43 CDT) Asst. City Manager May 4, 2021 Date May 4, 2021 Date Date Received May 5, 2021 $309,572.92 $23, 749.90 $333,322.82 $333,322.82 May 4, 2021 Date May 4, 2021 Date OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX Page 1 of 2 Notice of Project Completion Project Name: NORTH QUARTER 35 City Project No.: 102360 City's Attachments Final Pay Estimate x❑ Change Order(s): x❑ Yes ❑ N/A Pipe Report: x❑ Yes ❑ N/A Contractor's Attachments Affidavit of Bills Paid Consent of Surety , �.� �� Statement of Contract Time Contract Time: 30 WD Days Charged: 210 Work Start Date: 4/6/2020 Work Complete Date: 4/6/2021 Completed number of Soil Lab Test: 49 Completed number of Water Test: 38 Page 2 of 2 �'��r ��Tx CITY OF FORT WORTH FINAL PAYMENT REQUEST Contract Name NORTH QUARTER 35 Contract Limits Project Type WATER & SEWER City Project Numbers 102360 DOE Number 2360 Estimate Number 1 Payment Number 1 City Secretary Contract Number Contract Date Project Manager NA Contractor SYB CONSTRUCTiON COMPANY, INC. 421 COMPTON IRVING � TX 75061 Inspectors OWEN / MABRY For Period Ending 4/28/2021 W Contract Time 3�J Days Charged to Date 210 Contract is 100.00 Complete Monday, May 3, 2021 Page 1 of 5 City Project Numbers 102360 Contract Name NORTH QUARTER 35 Contract Limits Project Type WATER & SEWER Project Funding WATER DOE Number 2360 Estimate Number 1 Payment Number 1 For Period Ending 4/28/2021 Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total 1 12"PVCWATERPIPE 2136 LF $48.00 $102,528.00 2136 $102,528.00 2 8" PVC WATER PIPE 139 LF $36.00 $5,004.00 139 $5,004.00 3 6" PVC WATER PIPE 117 LF $30.00 $3,510.00 ll 7 $3,510.00 4 TRENCH SAFETY 2392 LF $0.10 $239.20 2392 $239.20 5 2" WATER SERVICE CO#2 8 EA $2,500.00 $20,000.00 8 $20,000.00 6 12" PVC WATER PIPE, CSS BACKFILL 80 LF $40.00 $3,200.00 80 $3,200.00 7 12" GATE VALVE 11 EA $2,200.00 $24,200.00 11 $24,200.00 8 8" GATE VALVE 6 EA $1,600.00 $9,600.00 6 $9,600.00 9 DUCTILE IRON WATER FITTINGS, 8 TN $631.84 $5,054.72 8 $5,054.72 W/RESTRAINT 10 CONNECTION TO EXISTING 24" WATER MAIN 2 EA $2,500.00 $5,000.00 2 $5,000.00 11 CONNECTION TO EXISTING 4"-12" WATER 1 EA $3,000.00 $3,000.00 1 $3,000.00 MAIN 12 FIRE HYDRANT 3 EA $2,800.00 $8,400.00 3 $8,400.00 13 24"Xl2" TAPPING SLEEVE & VALVE 1 EA $7,500.00 $7,500.00 1 $7,500.00 14 12"X8" TAPPING SLEEVE & VALVE 1 EA $3,500.00 $3,500.00 1 $3,500.00 15 CONNECTION TO EXIST 12" WTR MAIN CO#1 2 EA $1,800.00 $3,600.00 2 $3,600.00 16 12" WATER LINE LOWERING CO#1 30 LF $503.33 $15,099.90 30 $15,099.90 17 REMOVE 12" WATER LINE CO#1 30 LF $25.00 $750.00 30 $750.00 18 12" DUCTiLE IRON WATER PiPE CO#1 30 LF $60.00 $1,800.00 30 $1,800.00 Sub-Total of Previous Unit �22i,9ss.sz �221,9ss.s2 SEWER Item Description of Items No. 1 8" SEWER PIPE 2 8" DIP SEWER PIPE 3 TRENCHSAFETY 4 8" SEWER PIPE, CSS BACKFILL 5 8" DIP SEWER PIPE, CSS BACKFILL 6 CONCRETE ENCASE SEWER PIPE 7 4' MANHOLE Estimated Estimated Completed Completed Unit Unit Cost Quanity Total Quanity Total 930 LF $40.00 $37,200.00 930 $37,200.00 440 LF $50.00 $22,000.00 440 $22,000.00 1370 LF $0.10 $137.00 1370 $137.00 140 LF $40.00 $5,600.00 140 $5,600.00 60 LF $40.00 $2,400.00 60 $2,400.00 19 CY $100.00 $1,900.00 19 $1,900.00 5 EA $4,500.00 $22,500.00 5 $22,500.00 Monday, May 3, 2021 Page 2 of 5 City Project Numbers 102360 Contract Name NORTH QUARTER 35 Contract Limits Project Type WATER & SEWER Project Funding DOE Number 2360 Estimate Number 1 Payment Number 1 For Period Ending 4/28/2021 8 4' DROP MANHOLE 1 EA $7,600.00 $7,600.00 1 $7,600.00 9 TRENCH WATER STOPS 4 EA $3,000.00 $12,000.00 4 $12,000.00 Sub-Total of Previous Unit $ll1,337.00 $111,337.00 Monday, May 3, 2021 Page 3 of 5 City Project Numbers 102360 Contract Name NORTH QUARTER 35 Contract Limits Project Type WATER & SEWER Project Funding Contract Information Summary Origival Contract Amount Change Orders Change Order Number 1 Change Order Number 2 Total Contract Price DOE Number 2360 Estimate Number 1 Payment Number 1 For Period Ending 4/28/2021 $309,572.92 $21,249.90 $2,500.00 $333,322.82 Total Cost of Work Completed $333,322.82 Less % Retained $0.00 Net Earned $333,322.82 Earned This Period $333,322.82 Retainage This Period $0.00 Less Liquidated Damages Days @ / Day LessPavement Deficiency Less Penalty Less Previous Payment Plus Material on Hand Less 15% Balance Due This Payment $0.00 $0.00 $0.00 $0.00 $0.00 $333,322.82 Monday, May 3, 2021 Page 4 of 5 City Project Numbers 102360 Contract Name NORTH QUARTER 35 Contract Limits Project Type WATER & SEWER Project Funding DOE Number 2360 Estimate Number 1 Payment Number 1 For Period Ending 4/28/2021 Project Manager NA City Secretary Contract Number Inspectors OWEN / MABRY Contract Date Contractor SYB CONSTRUCTION COMPANY, INC. Contract Time 30 W 421 COMPTON Days Charged to Date 210 W IRVING, TX 75061 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 Less % Retained Net Earned Earned This Period $333,322.82 Retainage This Period $0.00 Less Liquidated Damages 0 Days @ $0.00 / Day LessPavement Deficiency Less Penalty Less Previous Payment Plus Material on Hand Less 15% Balance Due This Payment $333,322.82 $0.00 $333,322.82 $0.00 $0.00 $0.00 $0.00 $0.00 $333,322.82 Monday, May 3, 2021 Page 5 of 5 PROJECT NAME: PROJECT NUMBER: DOE NUMBER: PIPE LAID Yes Yes Yes FIRE HYDRANTS: 3 PIPE ABANDONED NA F�RT�C�RTH TRANSPORTATION AND PUBLIC WORKS PIPE REPORT FOR: North Quarter 35 102360 NA SIZE 12" g�� 6" SIZE NA WATER TYPE OF PIPE PVC PVC PVC VALVES (16" OR LARGER) TYPE OF PIPE LF 2136 139 117 LF DENSITIES: Yes NEW SERVICES: 4 Irrigation Copper 4 Domestic Copper SEWER PIPE LAID SIZE TYPE OF PIPE LF Yes 8" PVC Yes 8" DIP PIPE ABANDONED DENSITIES: NEW SERVICES: SIZE TYPE OF PIPE Yes LF 930 440 TRr�NSPORTATION AND PUBLIC WORKS �� The City of Fort Worth • 1000 Throckmorton Street • Fort Worth, TX 76012-6311 (817) 392 - 7941 • FaY: (817) 392 - 7845 0 � 0 O1 � (6 Q7 � � O � � v �� N (O � � � � � M � � � O O zz N N � G O O a� � � 0 Cl� _ C - � w C7 Q Z O� H� UU w� 0.. � � � z� � � U �a a o a a Q� z❑ 0 U N O O O O O O O � V o 0 0 0 0 0 � � � w � � � � x � U ..l �p i�- � W y � � a o 0 0 0 0 0 O o Ci � o 0 0 G! 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N O cA M M ❑ U y .. � �j o 0 0 0 0 0 � O z �' � w � �» w �» V � U ��r, w �n U Z N V � �a '� "' a � u�i u�i � M Z a N O O N O N ER O O n O O � O � w �, frs w w > a w �» � 0 U � ° o 0 0 0 0 0 �, o 0 0 0 0 0 t9 tn t9 tn t9 tn o � � V o W M � 3 M M W V1 O O o M � o o � o � w� a M O O �"� O M � O M O O M O M � fR 4'l Vi > V1 � � � N O V/ M M ❑ U a � o 0 0 0 0 0 U � � w � � w � � U rn W � Qo � � rn rn � N � o � .. �r+ o o ui o ui Nw u� ul � N O O N N � U rn `�' "`� rn o y o «n w � a�i C U � G F � Z W � � F O r a � K z � � Q � O � x _ ¢ � z � O ~ w U� O� O w Q w Q a Q c� � � cn �� a�� w a w w � o p O a Z v_� m � Q� O Q� o� � 0 a z o � � � F � � � w z O > � a O w U �U Q � ~ � � � � C d � 7 0 � U N C 0 U d C .3 0 0 � � � Y N � 0 � d U d � � � 0 � ri � c a � m O a a a N N � N � G O N � N � w ❑ � O w c� Z Q i � � LL N Z O Q w � C f� N — L — � �--� y"i � � U> C� Q� � � >. m °' � m z � U C � d m �U � N a �� c N O 2 e,�� E Y >. m C � � � � � � � C � m ai E � z a� � C .� � W .� U ai F � N O N � O L 4 Q � 4 cc N N � � y � W O � _ t ► � W � � m N � � � a 0 N N O � � .� � � v�i m z i= FORT��RTH� TRANSPORTATION AND PUBLIC WORKS April 27, 2021 SYB Construction 421 Compton Ave Irving, TX 75061 RE: Acceptance Letter Project Name: North Quarter 35 Project Type: Water, Sewer, Paving & Drainage City Project No.: 102360 To Whom It May Concern: On April 6, 2021 a final inspection was made on the subject project. There were punch list items identified at that time. The punch list items were completed on April 26, 2021. The final inspection and the corrected punch list items indicate that the work meets the City of Fort Worth specifications and is therefore accepted by the City. The warranty period will start on April 26, 2021, which is the date of the punch list completion 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- 392-6826. Sincerely, ��1� tfoG�et Mitch Holmes (May4, 202ll422CDT) Mitch Holmes, Project Manager Cc: Dennis Rodgers, Inspector Mark Owen, Inspection Supervisor Joe Rogers, Senior Inspector Cannon Henry, Program Manager Kimley-Horn & Associates, Consultant SYB Construction, Contractor Meritage Homes, Developer File E-Mail: TPW_Acceptance@fortworthtexas.gov Rev.8/20/19 Print �qrm Finai Bills Paid Afficlavif by Contractor BEFORE ME, the undersignecl authority, �ersonal[y appeared D�+vi�4 sq/ 6�c.�. (hereinafter referred to as "Contractoi"), lcnown fo i�e to be a cradi6le person, a.nd a�ter being by me duly sworn, upon oath stated ��id affirmed that: "My name is LijiN4E�- ��k� b� and I am fhe Dfw.s�--r Mqn+AC�rt o� SYd 4}+vsr¢uc�-,�N co. IN<. � here�fCer sometimes referred to in this af�da�it as "ContractoE•". Contractor's business address is �I�.1 cc,�fr7Wu q�v�� ¢vr�/� � Tjc. �.�aGl Tl�e undersigned Contractvr has personal knowled�e of the facts stated herein and has full authority ta make the agreements in this affidavit on behalf of Cor�tractor. Pursuant to and in accardance with a writteu constraction contract between S�� GJN9Ff�441}G+y �o ., I Nc, Contractor, and �w �� c;Gis�r��s �eN��pW��er/Administratar, Contractor fuc•nished materi�ls a�id labor for the construction, renovation, or repair of improvements located oiti or relating to project known as n/o�s-�4 G�u�o��- �� located at 5.3�''� ��a�o�M TSz.1An�� , City of '��r WortY�h , TA�ruea�n Coi�nty, Texas, legally described in Exhibit "A" attached hereto and made a part hereof i'or all pur�oses (the "ProperCy"). All work pro�ided far under said written construction contract, together with all changes and supplements thereio, lias been fully campleted in accordatice with the terms and �ro�isions thereof. Coniractor has paid each of its subcontracto��s, laborers, sup�liers and ma#erialmen in full for aEl labor and makerials provided to Contractor for or in connection with the construction, re��a�ation, or repair nf impro�ements on or relating to tlie subject Property, or any portion thereof, excepting only the an�ounts owecf for the following specified bills to the persons identi�ed below. Conh•actor warrants and represents that the following specifled bills will be paid to Contractor by �wner/Administrato�• in reliance on this Fiital Bills Paid Aifdavit: �Va�ne of Payee Address Teleplione No. Aanou��t Owed FG�.-r�rc�c+q � P�� .�11 E�or,nr w,c��vB�nrtaa �i b-'�'S8 -��i�� t�Ttr � wv s� 'Fsw `` � { - 3�•�3b�D Oiher ihan the abo�+e speeified bills owed to tlte abova referet�ced persons, Contractor is not aware of any unpaid bills, ciaiius, demands, or causes of action by any of i#s sttbcantractors, Eaborers, sappliers, o�• materia[meii for or in connectio�i with the furnishing of labor or in�teria�s, or both, for the constrttction, reno�ation, or repair of improve�nents located on or related to the su�ject Property. In consideration of the Punds paid to Contractor by Owner/Administrator and by Lender on behlif of Owner/Administrator in reli�nce on this af�davit, Contractor waives and releases all oTContractor's slatutoiy and constitutianAl tnechanic's lien rights connected with tlte constcuetion of the Projeot, conditioned oit the flcival payment or collection if payment is made by check or draft. Contractor further understand that this Final Bills Paid Affidavit is beii�g given pursuant to aud i�t accordance wit�� Sections 53.Q85 and 53.259 of the 'Fexas Propei�ty Code and that the intentional, ]<nowing, or reckless making of � false or misle�dii�g stateme��t in tl�is Affidavit constitutes an offense under said Sectioiti and is a Class A inisdemeanor. Contractor hereby indemnifies and holds harmless Owner/Administrator fi•om af�y and all claims, deroands or causes of �ction, and any costs, expenscs, and attorf�ey's fecs incurred in connection tl�erewith, arising from or conn�cted with, the statements and re�resei�tations contained l�erein." �orrn 16 -- �inal Bills f'aid Affidavit Page 1 of 3 � May '!, 2009 EX�,CUTED this � day of Notary's Acknawledgement �� , 2� �.� • ��j�GO�f�r'r�GfD�! Lv�Pl�f! '`�"�� [Name of Con�ractor Company] l � � By: /� Printed arne: r� r'� 1�i�j� �/.�i �� Title: �i^DJC G� /nQ'�Qy Pr / Before me, the undersigned authonty, on this day persanally appeared , tiv}�o first being dt�ly swo�� by me to be the pecson wl�ose name is subscribed to the foregoing Final Bills Paid Aifidavit, acknowIedged that he/she has the authority to make this Final Bills Paid �davit, and fu�ther acknowlec�ged fo me t[�at l�e/ she executed the satne for tlie purpose and consideration therein expressed. GIVEN UNDER MY HAND AND SEAL OF OFFICE oti this the 3� day of �R% , 2U �� 1 (Seal) Notary Public, State of Texas My connnissio�i expires Form 16 — Final BiEls Paid Affidavit Page 2 of 3 May 1, 2009 C(�NS�NT aF SURETY TO FiN�►L PAYlItIENT z�A,ar�u�a�t �7�17 Bonc� No. 1074780 'TO OVRI�i�R: (Atalne esxx'adcG'�j FW I-35 �ngistics Center, LLC � 75 Southwestern Avenue New Braunfels, TX 78130 fl�TRR A�:C.I�1T£`sCm cc��r�.c�� s�� c�� tCH�`��'�'S i�RC3J�CT �I�.: ��,�'�i�`�' ��: �0�15tfUCfl4�1 Jrit[7�'� C�N'�`�,A.�TDA'1"��]: February 1, 2020 rtau<:,F� Q�a�rfn,�� Paving, Drainage, Grading, Water and 5anitary Sewer to serve IVorth Quarter 35 �n acc:o�da�ce wrirh fF�� pta�FLs��ss �fti�e C�tracc i�u�een �t�� n�r arc� t� Cc�ritrac€tar as irsdit.�r.�� al.stn�, t�e �'#1tS�!'t nun¢e�pfsd ud�dfxsx of Sra�`e?i'I The Hanov�r Insurance Campany 440 Lincoln Street Worcester, MA 01653 r�n �innd c�f flr�rr �ranre arrd adrit�kst�"Car:lr�to�} � �'1 � 0 � , �i,i�F.� i�', SY8 Construction Company, Inc. 421 Connptan Ave. Irving, TX 75�61 , �ON'�itr�t.x"t�fi, tx��eby appresu��s af Fi�e iir�a# �aymcnc to the CanCraccnr, and �grees that �istaE payrtt�n� tt� tIa� �'c�tt��t�r sh�[4 nt�t r�li� tl�e S��ry �af any c�f ies t��iigatior�s to fl�l.st:'!r nu7ne t+raciackH`caa gj"Ou nsrr j FW I-35 Logistics Cenfier, LLC 175 Southwestern Avenue New Braunfieks, TX T8130 , o�%�, ciF1 SEt �C7�"C�3 �1 3� `�Ji3C�fjF"5 �1L)fiC�. 1.3v �N�Ss ��Oz�, che 5u��y �-�as hereun�n set �zs ��nc3 �n ��s dax�: May 3, 2021 (lr�1r� t�� tcv'1t1+{�{ �k�:uvr�fb,(dtvaer�ci#?t`e,tx` nrrmr+irrn rkrr� arrri��enr i .�tt��: t j , i (sea1�: ) ' s '"1 T�e HanoveY In�urance Campan� (,4ie�xNr3 , , � F� ey: � ,� _. _ __ '`� ES�f��urrr�jcrrrtbariz�freyN�rrr� hrl Laurie Pflug `` Attorney-in-Fact (Pe�rfax! rt�ueem atuirPtic� Surety Phone No. 508-853-7200 x-�k476 �'x7�7�--7 9�� SWISS RE CORPORATF SOLUTIONS NORTH AMERICAN SPECIALTY INSURANCE COMPANY WASHINGTON INTERl�ATIONAL INSURAIVCE COMYANY GEIVERA'L POWER QR ATTOANEY KNOW ALL MEN BY THES� 1'RESEIVTS, TIIA'T Nor�h llnxerica�� Specia6ry Insurazice Company, a corporation duly otganized and existir�g under taws ofthc State ofNew Iiainpshire, and having its pri�icipal off'ice inthc Ciry ofKansas Ci#y, Missouri, and Wast�ington Cntcrnatian.al Insurance Company, a corporation orga��ed aud existing under the la��s of thc Statc of New i�ampshire and having its prii�cipal of�'icc n� #1ie City of Kansas C;ity, Missauri, eacl3 does i-�ereby make, constitute and appoint: JACK M. CROWI.EY, STEVI:N R. FOSTER, TEU1'11 LURI AND LAURIF PI'LUG JOINTLY OR SEVERALLY Its tri�e and iawful Attocney{s)-in-Fact, to make, execute, seal a�id deli�er, for and on its behalf and as its act and deed, honcks or ather wrltings obligatory ii� the nature oFa bond on hehalf of each of said Com�,anies, as surety, on contracts of stEretyship as arc or may be req�ired or permi#ted by law, regulation, contract ar atherwise, pruvideci lhat no bond or undcrtaking ar co�rtract or surelyshEp executed under this authority sliall cxceed the amount of: F'IFTY MTLLiON (�50,fl00,000.00) DQLLARS ']'his Power of At�orney is granted a.nd is signed by facsimile under and by the authority ofti�e Following ltesolutions adopted by the Boards of Directors of both �lorth American Specialty� InsUrance Company and Washington International [nsurance Cnrnpany ai meetings duly called and he1cE on the 9"' oP May, 2012: "RESOLVED, lhat any rivo of the Presidents, auy Managitzg Director, any Seniar Vice President, arry Vice President, any Assistant Vice President the Secretzu y or az�y AssisEat�t Secretar}r be, and each or any of them hereby is auYl�of i�cd to execute a Power of Attorucy quaEifying the attorney nun�ed in ihe git�en Power of Attorney to cxccutc on behalf of Lhe Con�pany bonds, undertakin�s and all contracts of �urety, and tha[ each or any of them hereby is authorized to at�est to tk�e execution of any such Power of Attnrney aaad ta attach therein the seal of the Company; and it is FURTI3ER RLiSOLVEll, that the signature af s�ich o.fficers and the scal of the Company may be af#ixed to any such Pnwer ofi Attorney or to any certificabc rilating #hcrcto �y facsimile, anc� any such Powez oF Attorney or certificate bearing such Facsimile signaivres oe facsimile seal shall bc bindin�n u�on Che Cosnp�ny wltcn so afTxed and in tt3c futEuc with regard �o any bond, undertaking or coritract �f surety to �vhich i[ is attaclied." �a�•w�.S10 �4L li ��'�+., � ��'�'aRPflRq y`�G � 8y �s�;" c, rfi'•. Steven P. Auderyan. Senior 1''icr Pres9dent ot Washinn on Internatinnal Insurence Compuny S�f{�, � 5 s'�r ,n � & Senior Vice PrestUem oENorfh Ameripin 5peci:dq' Iasuraroee Company �� ; m z �. � �� s �'ka�'�,'C�`' � aa� �,y�� -• �� - *�R: MichAel A. FBt�,�or uc res. c��l o �gto� tcrnati� � u��U+ll�A�tAtlillu� & Seoior Vice P�sident oFNorth Americ�n Specialfy Insu�ante Company IN WITNESS WE-iFRrQF, Nnrtk� American 5pecialty Insurance Coinpany and Washingtc�n Inten�ational Insurance Comp�ry have caused their of�cial seals tn be heraua�to al�ixed, and these presents to be signed 6y their authorized of�Fcers this � 9t�� day of September , 20 �%. North r�merican Specialty Ins�rance Cump�ny Washington International Insurance Cornpany State of Illinois Caunty of Cook ss: On this 19th day oi'_ Septerober , 20 � y_, bei'ore me, a Notary {'uhlic personally appeared Steven P. Anderson , Senior Vice Presidcnt of Washington Intemational Insurance Company and Seuior Vice Psesident of NortE� American 5pec'ralty ]nsuranw Campany ar�d Michael A. ]to Seninr Vice 1'resident of Washsngton interrEattonal Insurance Compa�iy and Senior Vice President of ]�orth American Specialty Insuraa�ce Con,pany, personally known to rne, who being by me duty swom, acknowkedgcd tl�at they signed the a6ove Ppwer of Attorncy as offtcers of �ttd ac[cnowledged sa[d insti2nnent to be the volimtary act �nd deed of their respective campanies. OFF[[[AI. SEAL IA. KENHY Notary Put�lic - Staft nF illiunis Mp Lummissiun rxp��r.s iz+oa.zaz� - �� - - NL. iCenr+y, Notary Puhlec ,- I, JeFfre G�lr�hcr ihe daly elected llssisCant Secret��ry ofNorth American Speci�lty Insurance Company a�t�l Washington [nternational I��surance Company, do licre�y cettify lhat the above and foregaing is a true and correct co�y of a Power of Attorney given by said North I�m�rican �pecialty insurance Company and Washingtian lnternational �nsurar3ce Compat�y, wl�ich is still in full farce and efPect. IN WITNESS WH�RC4�", I have set my hand and affixed th� seais of the Companies this 3rd day of �� May , 20 21 �_ , . �. � r�� << ".r �_--,.. -� ]effrey (iolBberg. V[ce Pcesidznt & Assistank Sra:ratary of Waship�ton Irnernational Snsuranco Company & North American Specialiy lnsurance Comparsy Norkh American Specialfiy Insurance Company Washi�gton Infernational Insurance Company Westport Insurance Cotporation TEXAS CLAIMS �NFORIVlAT10N �MRORTA11iT NOTICE ADVISO IMPORTANTE Iro order ta obtain informatian or make a complaint You may contact Jeifrey Golcfberg, Vice President - Claims at 7-8Q0-33$-0753 Para o�te�er informacion o para someter un queja: Puede comunicarse con Jeffrey Goldberg, Vice President - Clairns, al 1-8d0-33$-0753 You may eall Was�ington Internationa[ Insurance Company and/or North American Special�Ey Insurance Company's and/or Westport Insurance Carporation tall-free nur�ber fior information ar to make a complaint at: 7 -8U0-338-0753 You may also write ta Washington International fnsura�ce Company and/or North American Specialty Insurance Company and/or Westport Insurance Corparation at the '#oilowing address: 1450 American Lane Su+te � 1 p0 5chaumburg, IL 50173 Usted puede Ilamr al numero de tele#ono gratis de Washington International Insurance Corrzpany and/or North American 5pecialty Insurance Company's and/or Wes#port Insurance Corporation para informacion o para snmeter una queja al: 1-$00-338-0753 Usted tambien puecie escribir a Washingtan international Insurance Company and/or Norfi�h American 5pecialty Insurance Company and/ar Westpork Insurance Corporation al: 145U American Lane S�ite 1100 Schaumburg, li. 60173 You may contact the Texas Department of tnsurance Puede escribir al Departmento de 5eguras de Texas to obtain information on companies, coverages, para ot�tener infarmacion acerca de companias, righis or complaints at: coberturas, derechos o q�ejas al: 1-$00-252-3439 You may wri#e the 7exas Department nf lnsurance: P.O. Box 7 49 7 D4 Austin, TX 7 87 1 4-9 1 04 Fax: {512} 475-1771 Web: ,h�n�/l�n►wr.tdi_stat�.tx.us Email: ConsumerProtection@tdi.state.�bc.us 1-800-252-3439 Pued� escribir al Departmento de Seguras de Texas: P.O. Bax 1491 D4 Austin, 7'X 78714-9104 Fax: [512) 475-'f 771 Web: httnJlur►w►ru.tdi.stat�.bc.us Ernail: ConsumerProtectio�@tdi,state.tx.us PREMIl1M OR CLAlM �ISPUTES: Should you have a dispute concerning your premium or about a claim you should first contact the Washingtan Internatior�al Insurance Company and/ar IVorth Arr�erican Speciai#y Insurance Company and/ar Wastport Insurance Corparation. If the dispute is nat resal�ed, you may contact the iexas Department of Insurance. AITAGti Tt1iS t110T�CE TQ YpUR PpLICY: This notice is for infprmation only and does not become a part or conditian of ihe attac�ed document. QISPUFAS 50BRE P�tIMAS O RECLAMOS: Si tiene una disputa concerniente a su prima o a un reclamo, debe cornunicarse con el Washington Interr�ational Insurance Company and/or lVorth American 5pecialty Insurance Company and/or Westport Insurance Corporation primero. Si no se resuel�e la d'+sputa, {�uede entonces comunicarse can el pepartmento de 5eguras de Texas. 11NA ESTE AVI50 A SU PO�IZp Este a�iso es solo �ara proposito de infromacion y no se canverte en parte p condicion de! documento adj u nta.