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HomeMy WebLinkAboutContract 54841-FP3 City Secretary 54841 -FP3 Contract No. FORTWORTH. Date Received Jan 19, 2022 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: Pioneer Point Phase 2 City Project No.: 102768 Improvement Type(s): Water 0 Sewer 0 Original Contract Price: $1,572,456.70 Amount of Approved Change Order(s): $54,172.60 Revised Contract Ammunt: Total Cost of Work Complete: $1,626,629.30 AGbee Czae gr Jan 15,2022 Albert Grantges(Jan 15,2Cf2 10:46 CST) Contractor Date Vice President Title Burnsco Construction, Inc. Company Name 4 a Jan 15,2022 Project Inspector Date Patrick dey(Ja 5,2022 22:17 CST) Jan 15,2022 Project Manager Date yanie scadett Mol'ales ^=Scarlett Morales(Jan 18,202207:5277) Jan 18,2022 CFA Manager Date Jan 18 2022 nana Riirghrinff(Ian 18 7 Asst. City Manager Date OFFICIAL RECORD CITY SECRETARY Page 1 of 2 FT. WORTH, TX Notice of Project Completion Project Name: Pioneer Point Phase 2 City Project No.: 102768 City's Attachments Final Pay Estimate ❑ 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: 120 WD Days Charged: 174 Work Start Date: 2/4/2021 Work Complete Date: 12/21/2021 Completed number of Soil Lab Test: 599 Completed number of Water Test: 43 Page 2 of 2 FORT WORTH CITY OF FORT WORTH FINAL PAYMENT REQUEST Contract Name WATER,SANITARY SEWER,STORM DRAIN,PAVING AND STREETLIG Contract Limits Project Type WATER&SEWER City Project Numbers 102768 DOE Number 2768 Estimate Number I Payment Number I For Period Ending 12/31/2021 WD City Secretary Contract Number Contract Time 209D Contract Date 10/22/2020 Days Charged to Date 174 Project Manager NA Contract is 100.00 Complete Contractor BURNSCO CONSTRUCTION,INC. 6331 SOUTHWEST BLVD FORT WORTH, TX 76132 Inspectors MILLER,W / CHATMAN,M Friday,January 14,2022 Page 1 of 6 City Project Numbers 102768 DOE Number 2768 Contract Name WATER,SANITARY SEWER,STORM DRAIN,PAVING AND STREETL Estimate Number 1 Contract Limits Payment Number 1 Project Type WATER&SEWER For Period Ending 12/31/2021 Project Funding UNIT I:WATER IMPROVEMENTS Item Estimated Estimated Completed Completed Description of Items Unit Unit Cost No. Quanity Total Quanity Total --------------------------------------- 1 8"WATER PIPE 4095 LF $27.00 $110,565.00 4095 $110,565.00 2 8"WATERLINE LOWERING 2 EA $4,450.00 $8,900.00 2 $8,900.00 3 1"WATER SERVICE 112 EA $890.00 $99,680.00 112 $99,680.00 4 1 1/2"WATER SERVICE 1 EA $1,700.00 $1,700.00 1 $1,700.00 5 2"WATER SERVICE 1 EA $1,800.00 $1,800.00 1 $1,800.00 6 8"GATE VALVE 20 EA $1,380.00 $27,600.00 20 $27,600.00 7 FIRE HYDRANT 4 EA $4,400.00 $17,600.00 4 $17,600.00 8 DUCTILE IRON WATER FITTINGS 5 TN $4,300.00 $21,500.00 5 $21,500.00 W/RESTRAINT 9 TRENCH SAFETY 4095 LF $0.10 $409.50 4095 $409.50 10 4"-12"PRESSURE PLUG 7 EA $150.00 $1,050.00 7 $1,050.00 11 CONNECT TO EXISTING 4:42"WATER MAIN 2 EA $1,100.00 $2,200.00 2 $2,200.00 12 AUTOMATIC FLUSH VALVE 1 EA $7,500.00 $7,500.00 1 $7,500.00 13 IMPORTED EMBEDMENT/BACKFILL,CSS 33.6 CY $137.50 $4,620.00 33.6 $4,620.00 -------------------------------------- Sub-Total of Previous Unit $305,124.50 $305,124.50 -------------------------------------- UNIT IA:24"WATER IMPROVEMENTS Item Estimated Estimated Completed Completed Description of Items Unit Unit Cost No. Quanity Total Quanity Total --------------------------------------- 1 24"WATER PIPE 1104 LF $158.00 $174,432.00 1104 $174,432.00 2 24"PRESSURE PLUG 1 EA $1,000.00 $1,000.00 1 $1,000.00 3 24"GATE VALVE W/VAULT 1 EA $32,500.00 $32,500.00 1 $32,500.00 4 CONNECTION TO EXISTING 24"WATER MAIN 1 EA $2,500.00 $2,500.00 1 $2,500.00 5 DUCTILE IRON WATER ITITINGS 2 TN $10,000.00 $20,000.00 2 $20,000.00 W/RESTRAINT 6 TRENCH SAFETY 1104 LF $1.00 $1,104.00 1104 $1,104.00 7 TRAFFIC CONTROL 1 MO $4,000.00 $4,000.00 1 $4,000.00 8 10'WIDE ASPHALT PVMT REPAIR,ARTERIAL 22 LF $210.00 $4,620.00 22 $4,620.00 -------------------------------------- Sub-Total of Previous Unit $240,156.00 $240,156.00 -------------------------------------- Friday,January 14,2022 Page 2 of 6 City Project Numbers 102768 DOE Number 2768 Contract Name WATER,SANITARY SEWER,STORM DRAIN,PAVING AND STREETL Estimate Number 1 Contract Limits Payment Number 1 Project Type WATER&SEWER For Period Ending 12/31/2021 Project Funding UN]Ir D:SANITARY SEWER IMPROVEMENTS Item Estimated Estimated Completed Completed Description of Items Unit Unit Cost No. Quanity Total Quanity Total --------------------------------------- 1 8"SEWER PIPE 3615 LF $40.00 $144,600.00 3615 $144,600.00 2 4'MANHOLE 13 EA $2,800.00 $36,400.00 13 $36,400.00 3 4'DROP MANHOLE 5 EA $4,400.00 $22,000.00 5 $22,000.00 4 IMPORTED EMBEDMENT/BACKFILL,CSS 49.6 CY $137.50 $6,820.00 49.6 $6,820.00 5 4'EXTRA DEPTH MANHOLE 36.8 VF $150.00 $5,520.00 36.8 $5,520.00 6 EPDXY MANHOLE LINER 57.3 VF $340.00 $19,482.00 57.3 $19,482.00 7 4'SEWER SERVICE 112 EA $715.00 $80,080.00 112 $80,080.00 8 6"SEWER SERVICE 1 EA $750.00 $750.00 1 $750.00 9 CONNECT TO EXISTING SANITARY SEWER 2 EA $700.00 $1,400.00 2 $1,400.00 10 TRENCH SAFETY 3615 LF $1.00 $3,615.00 3615 $3,615.00 11 POST-CCTV INSPECTION 3615 LF $3.60 $13,014.00 3615 $13,014.00 12 POST-CCTV INSPECTION MANHOLES 5 EA $300.00 $1,500.00 5 $1,500.00 13 MANHOLE VACUUM TESTING 18 EA $120.00 $2,160.00 18 $2,160.00 -------------------------------------- Sub-Total of Previous Unit $337,341.00 $337,341.00 UN]Ir IIA:OFFSITE SANITARY SEWER IMPROVEMEN Item Estimated Estimated Completed Completed Description of Items Unit Unit Cost No. Quanity Total Quanity Total --------------------------------------- 1 8"SEWER PIPE(CO A3,A4) 4628 LF $56.00 $259,168.00 4628 $259,168.00 2 8"SEWER CARRIER PIPE(CO A4) 1035 LF $67.00 $69,345.00 1035 $69,345.00 3 10"SEWER PIPE(CO A3) 210 LF $53.00 $11,130.00 210 $11,130.00 4 10"SEWER CARRIER PIPE 140 LF $76.10 $10,654.00 140 $10,654.00 5 4'MANHOLE(CO Al,A3) 20 EA $3,530.00 $70,600.00 20 $70,600.00 6 4'DROP MANHOLE 4 EA $5,240.00 $20,960.00 4 $20,960.00 7 4'EXTRA DEPTH MANHOLE(CO A3) 165.9 VF $150.00 $24,885.00 165.9 $24,885.00 8 EPDXY MANHOLE LINER(CO A3,A5,) 69.99 VF $340.00 $23,796.60 69.99 $23,796.60 9 20"CASING BY OPEN CUT 219 LF $115.00 $25,185.00 219 $25,185.00 10 20"CASING BY OTHER THAN OPEN CUT(CO 274 LF $538.00 $147,412.00 274 $147,412.00 A4) 11 CONCRETE ENCASEMENT FOR UTILITY PIPES 21.6 CY $381.25 $8,235.00 21.6 $8,235.00 12 CONNECT TO EXISTING SANITARY SEWER 1 EA $1,000.00 $1,000.00 1 $1,000.00 Friday,January 14,2022 Page 3 of 6 City Project Numbers 102768 DOE Number 2768 Contract Name WATER,SANITARY SEWER,STORM DRAIN,PAVING AND STREETL Estimate Number 1 Contract Limits Payment Number 1 Project Type WATER&SEWER For Period Ending 12/31/2021 Project Funding 13 TRENCH SAFETY(CO A3) 5932 LF $1.00 $5,932.00 5932 $5,932.00 14 POST CCTV INSPECTION(CO A3) 5932 LF $3.60 $21,355.20 5932 $21,355.20 15 POST-CCTV INSPECTION MANHOLES 7 EA $300.00 $2,100.00 7 $2,100.00 16 MANHOLE VACUUM TESTING(CO A3) 24 EA $120.00 $2,880.00 24 $2,880.00 17 8"SEWER ABANDONMENT PLUG 5 EA $50.00 $250.00 5 $250.00 18 UTILITY MARKERS 18 EA $90.00 $1,620.00 18 $1,620.00 19 CONCRETE COLLAR(CO A3) 24 EA $300.00 $7,200.00 24 $7,200.00 20 HAULOFF OF SPOILS FROM OFFSHT 125 LD $220.00 $27,500.00 125 $27,500.00 SANITARY SEWER 21 4'MANHOLE(CO A7) 1 EA $2,800.00 $2,800.00 1 $2,800.00 -------------------------------------- Sub-Total of Previous Unit $744,007.80 $744,007.80 -------------------------------------- Friday,January 14,2022 Page 4 of 6 City Project Numbers 102768 DOE Number 2768 Contract Name WATER,SANITARY SEWER,STORM DRAIN,PAVING AND STREETL Estimate Number 1 Contract Limits Payment Number 1 Project Type WATER&SEWER For Period Ending 12/31/2021 Project Funding Contract Information Summary Original Contract Amount $1,572,456.70 Change Orders Change Order Number Al $600.00 Change Order Number A3 $24,891.00 Change Order Number A4 $45,333.00 Change Order Number A5 ($19,451.40) Change Order Number A7 $2,800.00 Total Contract Price $1,626,629.30 Total Cost of Work Completed $1,626,629.30 Less %Retained $0.00 Net Earned $1,626,629.30 Earned This Period $1,626,629.30 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 $1,626,629.30 Friday,January 14,2022 Page 5 of 6 City Project Numbers 102768 DOE Number 2768 Contract Name WATER,SANITARY SEWER,STORM DRAIN,PAVING AND STREETL Estimate Number 1 Contract Limits Payment Number 1 Project Type WATER&SEWER For Period Ending 12/31/2021 Project Funding Project Manager NA City Secretary Contract Number Inspectors MILLER,W / CHATMAN,M Contract Date 10/22/2020 Contractor BURNSCO CONSTRUCTION,INC. Contract Time 200 WD 6331 SOUTHWEST BLVD Days Charged to Date 174 WD 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 $1,626,629.30 Less %Retained $0.00 Net Earned $1,626,629.30 Earned This Period $1,626,629.30 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 $1,626,629.30 Friday,January 14,2022 Page 6 of 6 k� � ƒ - _ © ): \ ` �9wd � Vk \ \ \ }\ �k § �2 «z3dd � \/ � \ / \ ® \ § !- k o mm = ° /CD ) � - . t �% — ?/j / � \c \ > � ^^ ® 09 ®m & § / / RM \ FIt It \ a 00/ CIS CR \ ) zz a %.o )/ $ \ - } ° E > ] 00 0 ƒ / § ) Ti \§ J:� U) EL '> Z v —_ m k ) 0 c w w § - 'oIN } ) \ ) \ \ \ / !- § ] " - - !! - ■ ° 0 bI D § § \% (D § �w k \ ( e } � \} j § _ y .. � �/ § mm § K : B■ B § § k * e � \ � 2 \ % § - - - - Lu LU ® ") ") ( § } ` R § \ \ § ( i ) )} ( \ ( ) ° \ N a 0 0 0 0 0 0 0 0 o a oo 000�n�n000 O�[7UO d1UOON �OG14�1�O NOtOM O co •t r r� }. 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TRANSPORTATION AND PUBLIC WORKS December 21, 2022 Burnsco Construction Inc. 6331 Southwest Blvd. Benbrook,TX 76132 RE: Acceptance Letter Project Name: Pioneer Point Phase 2 Project Type: Water, Sewer& Drainage City Project No.: 102768 To Whom It May Concern: On December 16, 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 January 21, 2022. 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 January 21, 2022, 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- 392-2443. Sincerely, Patrick dey(JarA5,2022 22:17 CST) Patrick Buckley, Project Manager Cc: Manuel Chatman, Inspector Wade Miller, Inspection Supervisor Emmanuel Nieto, Senior Inspector Victor Tornero, Program Manager Peloton Land Solutions, Consultant Burnsco Construction Inc., Contractor DR Horton,TX Ltd, Developer File E-Mail: TPW_Acceptance@fortworthtexas.gov Rev.8/20/19 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; Pioneer Point Phase 2 - Water, Sanitary Sewer and Storm Drain BY Ab Grantges4fontract Manager Subscribed and sworn before me on this date 22nd of December,2021. CESILIA CANALE5 z Notary ID 9131652996 My Commission Expires YJvr_,:rtt:Y July 24,2022 Notary Public Tarrant County,Texas CONSENT OF OWNER ❑ SURETY COMPANY ARCHITECT ❑ CONTRACTOR ❑ TO FINAL PAYMENT SURETY ❑ Conforms with the American Institute of OTHER Architects,AIA Document G707 Bond No 022228790 PROJECT: (name, address)Pioneer Point Phase 2-Water, Sanitary Sewer, Storm Drain Improvements TO (Owner) Fort Worth TX �' ID.R.HORTON-TEXAS,LTD AND CITY OF FORT ARCHITECT'S PROJECT NO: WORTH CONTRACT FOR: 6751 North Freeway Pioneer Point Phase 2-Water,Sanitary Sewer,Storm Drain Improvements Fort Worth TX 76131 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 Surely Company) LIBERTY MUTUAL INSURANCE COMPANY 175 Berkeley Street Boston MA 02116 , SURETY COMPANY on bond of (here insert name 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) D.R. HORTON-TEXAS, LTD AND CITY OF FORT WORTH 6751 North Freeway Fort Worth TX 76131 OWNER, as set forth in the said Surety Company's bond. IN WITNESS,WHEREOF, the Surety Company has hereunto set its hand this 22nd day of December, 2021 LIBERTY MUTUAL INSURANCE COMPANY Surety Company Attest, t, Seal ; .�_ i?'clw�:�t.-. Signatdre of Authorized Representative So hinie Hunter Attorney-in-Fact Title NOTE: This form is to be used as a companion document to AIA DOCUMENT G7C6, CONTRACTOR'S AFFIDAVIT OF PAYMENT OF DEBTS AND CLAIMS, Current Edition ONE 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. Liberty Liberty Mutual Insurance Company Mutual. The Ohio Casualty Insurance Company Certificate No: 8205467-022020 SURETY West American Insurance Company 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 organized 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, Don E. Cornell;Joshua Saunders;Kelly A.Westbrook;Mikaela Peppers;Ricardo J.Reyna;Robbi Morales;Sophinie Hunter;Tina McEwan;Tonic Petranek all of the city of Dallas state of TX each individually if there be more than one named,its true and lawful attomey-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 tf 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 the Companies have been affixed thereto this 23rd day of April 2021 Liberty Mutual Insurance Company P�114SU"pq pV111 INS& 1NSURR The Ohio Casualty Insurance Company JJ 2GORPnxgr� �4oRroxyrF'egyn °Rapo'r'� West American Insurance Company � 1912 � 0 0a1919� 0 1991 0 d� 7 CHUS�da O y NA Y�NOIANP�a 3 B Q7 0 y• c} m ca ca State of PENNSYLVANIA David M.Carey,Assistant Secretary a m County of MONTGOMERY U a o On this 23rd day of April 2021 before me personally appeared David M.Carey,who acknowledged himself to be the Assistant Secretary of Liberty Mutual Insurance a� Il 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. `m a N cs > ::' 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. Q in o °� [L O - Commonwealth of Pennsylvania-Notary Seal T_ Q} O - - Teresa Pastella,Notary Public n �. 6 - Montgomery County . L - - My commission expires March 28,2025 By• /ram U Commission number 1126044 - �� Member,Pennsylvania Association of Warier eresa PaStella,Notary Public Q p` N p0 This Power of Attorney is made and executed pursuant to and by authority of the following By-laws and Authorizations of The Ohio Casualty Insurance Company, Liberty Mutual e) Insurance Company,and West American Insurance Company which resolutions are now In full force and effect reading as foliows: o cu aS a ARTICLE]V—OFFICERS:Section 12.Power of Attorney. r o io Any officer or other official of the Corporation authorized for that purpose in wr ting by the Chairman or the President, and subject to such limitation as the Chairman or the DC President may prescribe,shall appoint such attomeys-in-fact,as may be necessary to act in behalf of the Corporation to make,execute,seal,acknowledge and deliver as surety m r° 7 N 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 -a 6 = 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 o m Z instruments shall be as binding as if signed by the President and attested to b the Secrets An y Secretary. y power or authority granted to any representative or attorney-in-fact under the-2 'Mn 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. Li 9 ARTICLE XIII—Execution of Contracts;Section 5.Surety Bonds and Undertakings. 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, shall appoint such attomeys-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 attomeys-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 Tuff,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 22nd day of December , 2021 P4 SNSURq j P"-0 INS& � SN181),.`oKPor�r�2m �J=ooRPor�,yl'Q92aRPo��y 2 F4 n 7 =� Ta c4 Y 9s1912 y�o s Z. 1919� o a 1991 0 By aka p�yAMPs��,aa� �Sl��h'OlANP�,aa� Renee C.Llewellyn,Assistant Secretary LMS-12e73 Ll OCIC WAIC Mufti Co 02121 . t17 10, �Mutua't. - SURETY TEXAS TEXAS IMPORTANT NOTICE AVISO IMPORTANTE To obtain information or make a complaint: Para obtener information o para someter una queja: You may call toll-free for information or to Usted puede 11amar al 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 I I-1A) de Texas Consumer Protection (I I 1-IA) P. O. Box 149091 P. O. Box 149091 Austin, TX 78714-9091 Austin, TX 78714-9091 FAX: (512)490-1007 FAX 9 (512) 490-1007 Web: http://www.tdi.texas.gov Web: http://www.tdi.texas.g_ov E-mail: ConsumerProtection tdi.texas. ov E-mail: ConsumerProtection tdi.texas. ov 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 T141S 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 infonnacion become a part or condition of the attached y no se convierte en pane o condition del document. documento adjunto. NP70680901 LMS-15292 10115