HomeMy WebLinkAboutContract 55972-FP1 City Secretary 55972 -FP1
Contract No.
FORT WORTH., Date Received Sept. 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: Litsey Creek Cottages
City Project No.: 103173
Improvement Type(s): Water 0 Sewer 0
Original Contract Price: $544,151.80
Amount of Approved Change Order(s): $64,518.00
Revised Contract Amount:
Total Cost of Work Complete: $608,669.80
14
Samuel Heath(Sep 14,202210:52 CDT) Sep , 2022
Contractor Date
Project Manager
Title
Ridgemont
Company Name
RileyR ep ,2 2211:26CDT) Sep 14, 2022
Project Inspector Date
Kiran Konduru,P.E.(Sep 14,202213:03 CDT) Sep 14 2022
Project Manager Date
Lgf/G1�11 ffoGG�tGoy Sep 14, 2022
Dwavne ollars for(Sep 14,2022 3:24 CDT)
CFA Manager Date
—P Sep 14, 2022
Interim TPW Director Date
William Johnson(S 14,202214:05 CDT) Sep 14, 2022
Asst. City Manager Date
OFFICIAL RECORD
CITY SECRETARY
Page 1 of 2
FT. WORTH, TX
Notice of Project Completion
Project Name: Litsey Creek Cottages
City Project No.: 103173
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 Affidavit of Bills Paid
Consent of Surety 4M
Consent of Surety
Statement of Contract Time
Contract Time: 150 WD Days Charged: 216
Work Start Date 08/23/2021 Work Complete Date: 8/2/2022
Soil Lab Number of Tests 284
Water Number of Tests: 29
Page 2 of 2
FORT WORTH
CITY OF FORT WORTH
FINAL PAYMENT REQUEST
Contract Name LITSEY CREEK COTTAGES
Contract Limits
Project Type WATER&SEWER IMPROVEMENTS
City Project Numbers 103173
DOE Number 1730
Estimate Number 1 Payment Number 1 For Period Ending 8/2/2022
WD
City Secretary Contract Number Contract Time 15WD
Contract Date 6/22/2021 Days Charged to Date 216
Project Manager NA Contract is 100.00 Complete
Contractor RIDGEMONT COMPANY
1520 W.WALNUT HILL LANE
IRVING, TX 75038
Inspectors GLOVER/ ROBERSON
Monday,September 12,2022 Page 1 of 5
City Project Numbers 103173 DOE Number 1730
Contract Name LITSEY CREEK COTTAGES Estimate Number 1
Contract Limits Payment Number 1
Project Type WATER&SEWER IMPROVEMENTS For Period Ending 8/2/2022
Project Funding
UNIT I WATER IMPROVEMENTS
Item Estimated Estimated Completed Completed
Description of Items Unit Unit Cost
No. Quanity Total Quanity Total
1 FIRE HYDRANT STEM EXTENSION 1 EA $4,420.00 $4,420.00 1 $4,420.00
2 TRENCH SAFETY 2923 LF $1.00 $2,923.00 2923 $2,923.00
3 DUCTILE IRON WATER FITTINGS 4.5 TN $968.00 $4,356.00 4.5 $4,356.00
W/RESTRAINT
4 6"PVC WATER PIPE 102 LF $27.00 $2,754.00 102 $2,754.00
5 8"PVC WATER PIPE 2525 LF $35.00 $88,375.00 2525 $88,375.00
6 8"PVC WATER PIPE,CLSM BACKFILL 110 LF $96.50 $10,615.00 110 $10,615.00
7 12"PVC WATER PIPE 171 LF $48.00 $8,208.00 171 $8,208.00
8 12"PVC WATER PIPE,CLSM BACKFILL 15 LF $104.00 $1,560.00 15 $1,560.00
9 FIRE HYDRANT 2 EA $4,180.00 $8,360.00 2 $8,360.00
10 CONNECTION TO EXISTING 4"-12"WATER 2 EA $847.00 $1,694.00 2 $1,694.00
MAIN
11 1 1/2"WATER SERVICE 6 EA $2,300.00 $13,800.00 6 $13,800.00
12 2"WATER SERVICE 4 EA $2,900.00 $11,600.00 4 $11,600.00
13 4"WATER METERAND VAULT 2 EA $11,800.00 $23,600.00 2 $23,600.00
14 6"GATE VALVE 3 EA $1,050.00 $3,150.00 3 $3,150.00
15 8"GATE VALVE 6 EA $1,400.00 $8,400.00 6 $8,400.00
16 12"GATE VALVE 2 EA $2,200.00 $4,400.00 2 $4,400.00
Sub-Total of Previous Unit $198,215.00 $198,215.00
UNIT II SEWER IMPROVEMENTS
Item Estimated Estimated Completed Completed
Description of Items Unit Unit Cost
No. Quanity Total Quanity Total
1 REMOVE 12"SEWER LINE 1400 LF $25.00 $35,000.00 1400 $35,000.00
2 REMOVE T SEWER MANHOLE 2 EA $800.00 $1,600.00 2 $1,600.00
3 CONCRETE ENCASE SEWER PIPE 2 CY $280.00 $560.00 2 $560.00
4 CONC PVMT REPAIR,HES, 201 SY $410.80 $82,570.80 201 $82,570.80
ARTERIALANDUSTRIAL
5 PRE-CCTV INSPECTION 1400 LF $1.00 $1,400.00 1400 $1,400.00
6 POST-CCTV INSPECTION 2706 LF $1.00 $2,706.00 2706 $2,706.00
7 MANHOLE VACUUM TESTING 13 EA $100.00 $1,300.00 13 $1,300.00
8 MANHOLE ADJUSTMENT,MAJOR 1 EA $9,194.00 $9,194.00 1 $9,194.00
Monday,September 12,2022 Page 2 of 5
City Project Numbers 103173 DOE Number 1730
Contract Name LITSEY CREEK COTTAGES Estimate Number 1
Contract Limits Payment Number 1
Project Type WATER&SEWER IMPROVMENTS For Period Ending 8/2/2022
Project Funding
9 TRENCH SAFETY 2770 LF $1.00 $2,770.00 2770 $2,770.00
10 CONCRETE COLLAR 6 EA $500.00 $3,000.00 6 $3,000.00
11 4"SEWER SERVICE 7 EA $1,096.00 $7,672.00 7 $7,672.00
12 6"SEWER SERVICE 1 EA $1,300.00 $1,300.00 1 $1,300.00
13 8"SEWER PIPE 68 LF $36.00 $2,448.00 68 $2,448.00
14 10"SEWER PIPE 1135 LF $41.00 $46,535.00 1135 $46,535.00
15 12"SEWER PIPE 1178 LF $17.00 $20,026.00 1178 $20,026.00
16 12"SEWER PIPE,CSS BACK FILL 45 LF $103.00 $4,635.00 45 $4,635.00
17 15"SEWER PIPE 324 LF $84.75 $27,459.00 324 $27,459.00
18 15"SEWER PIPE,CSS BACKFILL 20 LF $140.95 $2,819.00 20 $2,819.00
19 EPDXY MANHOLE LINER 232 VF $195.00 $45,240.00 232 $45,240.00
20 T MANHOLE 14 EA $2,630.00 $36,820.00 14 $36,820.00
21 T EXTRADEPTH MANHOLE 89.5 VF $200.00 $17,900.00 89.5 $17,900.00
21 CONNECT TO EX.SEWER MANHOLE 2 EA $2,000.00 $4,000.00 2 $4,000.00
22 SPECIFIED REMOBLIZATION 1 EA $12,500.00 $12,500.00 1 $12,500.00
23 24"CASING BY OPEN CUT 20 LF $445.00 $8,900.00 20 $8,900.00
24 TRAFFIC CONTROL 2 MO $16,050.00 $32,100.00 2 $32,100.00
Sub-Total of Previous Unit $410,454.80 $410,454.80
Monday,September 12,2022 Page 3 of 5
City Project Numbers 103173 DOE Number 1730
Contract Name LITSEY CREEK COTTAGES Estimate Number 1
Contract Limits Payment Number 1
Project Type WATER&SEWER IMPROVMENTS For Period Ending 8/2/2022
Project Funding
Contract Information Summary
Original Contract Amount $544,151.80
Change Orders
Change Order Number 1 $64,518.00
Total Contract Price $608,669.80
Total Cost of Work Completed $608,669.80
Less %Retained $0.00
Net Earned $608,669.80
Earned This Period $608,669.80
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 $608,669.80
Monday,September 12,2022 Page 4 of 5
City Project Numbers 103173 DOE Number 1730
Contract Name LITSEY CREEK COTTAGES Estimate Number 1
Contract Limits Payment Number 1
Project Type WATER&SEWER IMPROVMENTS For Period Ending 8/2/2022
Project Funding
Project Manager NA City Secretary Contract Number
Inspectors GLOVER/ ROBERSON Contract Date 6/22/2021
Contractor RIDGEMONT COMPANY Contract Time 150 WD
1520 W.WALNUT HILL LANE Days Charged to Date 216 WD
IRVING, TX 75038 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 $608,669.80
Less %Retained $0.00
Net Earned $608,669.80
Earned This Period $608,669.80
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 $608,669.80
Monday,September 12,2022 Page 5 of 5
FORT WORT H
"W
TRANSPORTATION AND PUBLIC WORKS
PIPE REPORT FOR:
PROJECT NAME: Litsey creek Cottages
CITY PROJECT NUMBER: 103173
WATER
PIPE LAID SIZE TYPE OF PIPE LF
PVC 6" PVC Water 102 LF
PVC 8" PVC Water 2525LF
PVC 12" PVC WAter 171LF
FIRE HYDRANTS: 2 VALVES(16" OR LARGER) N/A
PIPE ABANDONED SIZE TYPE OF PIPE LF
DENSITIES:
NEW SERVICES: 2 4" DIP
6 1 1/2 " Copper
4211 Copper
SEWER
PIPE LAID SIZE TYPE OF PIPE LF
PVC 12" Sewer PVC 1178LF
PVC 8" Sewer PVC 68LF
PVC 10" Sewer PVC 1135LF
PVC 15" Sewer PVC 324LF
PIPE ABANDONED SIZE TYPE OF PIPE LF
PVC 12" Sewer PVC 140OLF
DENSITIES:
NEW SERVICES: 7411 Sewer Services
1611 Sewer Services
TRANSPORTATION AND PUBLIC WORKS
The City of Fort Worth• 1000 Throckmorton Street•Fort Worth,TX 76012-6311
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FORTWORTH.
TRANSPORTATION AND PUBLIC WORKS
August 25,2022
Ridgemont Residntial
1520 W.Walnut Hill Ln.
Irving,TX. 75038
RE: Acceptance Letter
Project Name: Litsey Creek Cottages
Project Type: Water,Sewer, Paving, Drainage &Street Lights
City Project No.: 103173
To Whom It May Concern:
On August 2, 2022 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 August 25, 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 August 25, 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 682-
201-6278.
Sincerely,
Kiran Konduru,P.E.(Sep 14,202213:03 CDT)
Kiran Konduru, Project Manager
Cc: Riley Roberson, Inspector
Mike Glover, Inspection Supervisor
Daniel Roy, Senior Inspector
Victor Tornero, Program Manager
John D. Ainsworth, Consultant
Ridgemount Residentia, Contractor
MCA Litsey Creek Owner LP, Developer
File
E-Mail: TPW_Acceptance@fortworthtexas.gov
Rev.8/20/19
Affidavit of Bills Paid (Stationary).d ocx Aa
AFFIDAVIT
STATE OF Texas
COUNTY OF Dallas
Before me, the undersigned authority, a notary public in the state and county
aforesaid, on this day personally appeared Name, Title Of Company, 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;
Contract rlption Litsey Creek Endeavor#103173
BY
Nam r Title Kevin D.Mezger
Principal
Subscribed and sworn before me on this 8th Day =116M4-72
,
Q� Yp RNE R
blic
Notary Public Donna Turner /V EXAS
� OFPg MyComm.Exp.12123J2Q23
County, State Dallas County,Texas 80884m2
� ...
NOTICE:
This document waives rights unconditionally and states that you have been
paid for giving up those rights. It is prohibited for a person to require you to sign
this document if you have not been paid the payment amount set forth below. If you
have not been paid, use a conditional release form.
UNCONDITIONAL WAIVER AND RELEASE ON FINAL PAYMENT
Project CFA#2 _ Litsey Creek Endeavor
Job No. 103173
The signer of this document has been paid in full for all labor, services,
equipment, or materials furnished to the property or to MCA Litsey Creek Owner LP
(person with whom signer contracted) on the property of MCA Litsey Creek Owner
LP (owner) located at 6501 Oak Grove Rd., Ft .Worth, TX (location) to the following
extent: Litsey Creek Endeavor Project#103173 Oob description).
The signer therefore waives and releases any mechanic's lien right, any right
arising from a payment bond that complies with a state or federal statute, any common
law payment bond right, any claim for payment, and any rights under any similar
ordinance, rule, or statute related to claim or payment rights for persons in the signer's
position.
The signer warrants that the signer has already paid or will use the funds received
from this final payment to promptly pay in full all of the signer's laborers, subcontractors,
materialmen, and suppliers for all work, materials, equipment, or services provided for or
to the above referenced project up to the date of this waiver and release.
Date 8/8/22
Ridgemont Residential,LLC (Company name)
By (Signature)
Member (Title)
SUBSCRIBED AND SWORN TO BEFORE ME, the undersigned, a Notary Public on
this 8th day of August, 2022 to certify which witness by hand and seal of office.
DONNATURNER
Notary Public
* * STATE OF TEXAS
My Comm.Exp.1212aQ023 Notary Public, State of Texas
l� NOTARY ID 116a884.2
CONSENT OF OWNER
SURETY COMPANY ARCHITECT
TO FINAL PAYMENT CONTRACTOR
SURETY
AIA DOCUMENT G707 OTHER
Bond No. PRF9382554
PROJECT: Water, Sewer, Paving,Drainage, and Street Light Improvements to serve Litsey Creek
(name,address) Cottages, CFA21-0045,Fort Worth,TX
TO(Owner) [ City of Fort Worth and ] ARCHITECT'S PROJECT NO:
MCA Litsey Creek Owner,LP
CONTRACT FOR:
] CONTRACT DATE:
CONTRACTOR: Ridgemont Residential, LLC
1520 W. Walnut Hill Lane
Irving, TX 75038
In accordance with the provisions of the Contract between the Owner and the Contractor as indicated above,the
(here insert name and address of Surety Company)
Colonial American Casualty and Surety Company
1299 Zurich Way, 5th Floor
Schaumburg,IL 60196-1056 , SURETY COMPANY,
on bond of(here insert name and address of Contractor)
Ridgemont Residential,LLC
1520 W. Walnut Hill Lane
Irving,TX 75038 , CONTRACTOR,
hereby approves of the final payment to the Contractors, 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)
City of Fort Worth and MCA Litsey Creek Owner, LP
,OWNER,
as set forth in the said Surety Company's bond.
IN WITNESS WHEREOF,
the Surety Company has hereunto set its hand this 13th day of September 2Q22
Colonial American Casualty and Surety Company
Surety Company
Signature of Authorized Representative
Attest:
(Seal): Debra Lee Moon Attoriiey-In-,Fact
Title -
NOTE: This form is to be used as a companion document to AIA DOCUMENT G706,CONTRACTOR'S AFFIDAVIT OF PAYMENT OF Dl;b.TS AND CLA_s,
Current Edition
AIA DOCUMENT 6707 CONSENT OF SURETY COMPANY TO FINAL PAYMENT APRIL 1970 EDITION AIA ONE PAGE
1970 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 New York Ave.,NW,WASHINGTON,D.C. 20006
ZURICH AMERICAN INSURANCE COMPANY
COLONIAL AMERICAN CASUALTY AND SURETY COMPANY
FIDELITY AND DEPOSIT COMPANY OF MARYLAND
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS:That the ZURICH AMERICAN INSURANCE COMPANY,a corporation of the State of Now
York, the COLONIAL AMERICAN CASUALTY AND SURETY COMPANY, a corporation of the State of Illinois, and the FIDELITY
AND DEPOSIT COMPANY OF MARYLAND a corporation of the State of Illinois (herein collectively called the "Companies"), by
Robert D.Murray,Vice President,in pursuance of authority granted by Article V,Section 8,of the By-Laws of said Companies,which are
set forth on the reverse side hereof and are hereby certified to be in full force and effect on the date hereof,do hereby nominate,constitute,
and appoint Sammy Joe MULLIS,JR., Suzanne Elizabeth NIEDZWIEDZ,John William NEWBY,Joshua D.TRITT,Sandra Lee
RONEY,Debra Lee MOON,Andrea Rose CRAWFORD,Troy Russell KEY,Cheri Lynn IRBY of Addison,Texas,EACH,its true
and lawful agent and Attorney-in-Fact,to make,execute,scat and deliver,for,and on its behalf as surety,and as its act and deed: any and
all bonds and undertakings,and the execution of such bonds or undertakings in pursuance of these presents,shall be as binding upon said
Companies,as fully and amply,to all intents and purposes, as if they had been duly executed and acknowledged by the regularly elected
officers of the ZURICH AMERICAN INSURANCE COMPANY at its office in New York,New York.,the regularly elected officers of the
COLONIAL AMERICAN CASUALTY AND SURETY COMPANY at its office in Owings Mills, Maryland., and the regularly elected
officers of the FIDELITY AND DEPOSIT COMPANY OF MARYLAND at its office in Owings Mills, Maryland., in their own proper
persons.
The said Vice President does hereby certify that the extract set forth on the reverse side hereof is a true copy of Article V,Section 8,of
the By-Laws of said Companies,and is now in force.
IN WITNESS WHEREOF, the said Vice-President has hereunto subscribed his/her names and affixed the Corporate Seals of the said
ZURICH AMERICAN INSURANCE COMPANY, COLONIAL AMERICAN CASUALTY AND SURETY COMPANY, and
FIDELITY AND DEPOSIT COMPANY OF MARYLAND,this 19th day of February,A.D.2021.
o
co
ATTEST:
ZURICH AMERICAN INSURANCE COMPANY
COLONIAL AMERICAN CASUALTY AND SURETY COMPANY
FIDELITY AND DEPOSIT COMPANY OF MARYLAND
By: Robert D. Murray
Vice President
By: Dawn E.Brown
Secretary
State of Maryland
County of Baltimore
On this 19th day of February, A.D.2021, before the subscriber,a Notary Public of the State of Maryland,duly commissioned and qualified,Robert D.
Murray,Vice President and Dawn E.Brown,Secretary of the Companies,to me personally known to be the individuals and officers described in and who----
executed the preceding instrument,and acknowledged the execution of same,and being by me duly sworn,deposeth and saith,that he/she is the said oflricer of--' _
the Company aforesaid,and that the seals affixed to the preceding instrument are the Corporate Seals of said Companies,and that the said Corporate,6eals and
the signature as such officer were duly affixed and subscribed to the said instrument by the authority and direction of the said Corporations.
IN TESTIMONY WHEREOF,I have hereunto set my hand and affixed my Official Seal the day and year first above written.
;_
CL
_
Constance A.Dunn,Notary Public
L
ry
';' „���'' My Commission Expires:July 9,2023
Authenticity of this bond can be confirmed at bondvalidator.zurichna.com or 410-559-8790
EXTRACT FROM BY-LAWS OF THE COMPANIES
"Article V,Section 8,Attorneys-in-Fact.The Chief Executive Officer,the President,or any Executive Vice President or Vice President
may, by written instrument under the attested corporate seal, appoint attorneys-in-fact with authority to execute bonds, policies,
recognizances, stipulations, undertakings, or other like instruments on behalf of the Company, and may authorize any officer or any such
attorney-in-fact to affix the corporate seal thereto;and may with or without cause modify of revoke any such appointment or authority at any
time."
CERTIFICATE
I, the undersigned, Vice President of the ZURICH AMERICAN INSURANCE COMPANY, the COLONIAL AMERICAN
CASUALTY AND SURETY COMPANY, and the FIDELITY AND DEPOSIT COMPANY OF MARYLAND, do hereby certify that
the foregoing Power of Attorney is still in full force and effect on the date of this certificate;and I do further certify that Article V,Section
8,of the By-Laws of the Companies is still in force.
This Power of Attorney and Certificate may be signed by facsimile under and by authority of the following resolution of the Board of
Directors of the ZURICH AMERICAN INSURANCE COMPANY at a meeting duly called and held on the 15th day of December 1998.
RESOLVED:"That the signature of the President or a Vice President and the attesting signature of a Secretary or an Assistant Secretary
and the Seal of the Company may be affixed by facsimile on any Power of Attorney...Any such Power or any certificate thereof bearing such
facsimile signature and seal shall be valid and binding on thcCompany."
This Power of Attorney and Certificate may be signed by facsimile under and by authority of the following resolution of the Board of
Directors of the COLONIAL AMERICAN CASUALTY AND SURETY COMPANY at a meeting duly called and held on the 5th day of
May, 1994, and the following resolution of the Board of Directors of the FIDELITY AND DEPOSIT COMPANY OF MARYLAND at a
meeting duly called and held on the 1 Oth day of May,1990.
RESOLVED:"That the facsimile or mechanically reproduced seal of the company and facsimile or mechanically reproduced signature of
any Vice-President, Secretary, or Assistant Secretary of the Company, whether made heretofore or hereafter, wherever appearing upon a
certified copy of any power of attorney issued by the Company,shall be valid and binding upon the Company with the same force and effect
as though manually affixed.
IN TESTIMONY WHEREOF,I have hereunto subscribed my name and affixed the corporate seals of the said Companies,
this 13th day of September , 2022
of 8SAL
4 Ww �Ma'*iMN�
By: Brian M.Hodges
Vice President
TO REPORT A CLAIM WITH REGARD TO A SURETY BOND,PLEASE SUBMIT A COMPLETE DESCRIPTION
OF THE CLAIM INCLUDING THE PRINCIPAL ON THE BOND,THE BOND NUMBER,AND YOUR CONTACT
INFORMATION TO:
Zurich Surety Claims
1299 Zurich Way
Schaumburg,IL 60196-1056
www.EMortsfclaims(a�zurichna.com
800-626-4577
ZURICHy
Texas Important Notice
IMPORTANT NOTICE AVISO IMPORTANTE
To obtain information or make a complaint: Para obtener informaci6n o para presentar una queja:
You may call Zurich North America's toll-free telephone Usted puede Ilamar al numero de telefono gratuito de
number for information or to make a complaint at: Zurich North America's para obtener informacion o para
1-800-382-2150 presentar una queja al:
1-800-382-2150
You may contact the Texas Department of Insurance to
obtain information on companies, coverages, rights, or Usted puede comunicarse con el Departamento de Se-
complaints at: guros de Texas para obtener informacion sobre com-
1-800-252-3439 panias, coberturas, derechos, o quejas al:
1-800-252-3439
You may write the Texas Department of
Insurance: Usted puede escribir al Departamento
P.O. Box 149104 de Seguros de Texas a:
Austin,TX 78714-9104 P.O. Box 149104
Fax: (512)490-1007 Austin,TX 78714-9104
Web: www.tdi.texas.gov Fax: (512)490-1007
E-mail: ConsumerProtection@tdi.texas.gov Sitio web: www.tdi.texas.gov
E-mail: ConsumerProtection@tdi.texas.gov
PREMIUM OR CLAIM DISPUTES:
Should you have a dispute concerning your premium or DISPUTAS POR PRIMAS DE SEGUROS O
about a claim, you should contact the company first. If RECLAMACIONES:
the dispute is not resolved, you may contact the Texas Si tiene una disputa relacionada con su prima de seguro
Department of Insurance. o con una reclamaci6n, usted debe comunicarse con la
compaflia primero. Si la disputa no es resueita, usted
ATTACH THIS NOTICE TO YOUR POLICY: puede comunicarse con el Departamento de Seguros de
This notice is for information only and does not become Texas.
a part or condition of the attached document.
ADJUNTE ESTE AVISO A SU P6LIZA: Este aviso es
solamente para prop6sitos informativos y no se con-
vierte en parte o en condici6n del documento adjunto.
U-GU-296-E(06/15)
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