HomeMy WebLinkAboutContract 49607-FP3 FORTWORTH, CITY SECRETARY
CONTRACT N0. "l 3
TRANSPORTATION AND PUBLIC WORKS
NOTICE OF PROJECT COMPLETION
(Developer Projects)
0aml ea( -51iz, � City Project NO: 101000
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Regarding contract 101000 for LIVE OAK PHASE 3A as required by the
TRANSPORTATION&PUBLIC WORKS as approved by City Council on N/A through M&C N/A the director
of the TRANSPORTATION&PUBLIC WORKS upon the recommendation of the Assistant Director of the
Transportation&Public Works Department has accepted the project as complete.
� � m
Original Contract Price: i t .o r $517,830.75
Amount of Approved Change Orders: 1 r c i Ns
U) .r 0 E 4'Revised Contract Amount: o c a E
Total Cost Work Completed: �_ -Q c t $517,830.75
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RecommendIIIfo Acceptance Date
Asst. Directo , P - Development Services
Accepted Date
4ft%Dir+�Director, TRANSPORT TIO & PUBLIC WORKS
�.i2�a
Ass . Cit Manager Date
OFFICIAL RECORD
Comrne�nts•
CITY SECRETARY
FT.WORTH,TX
Rev.9/22/16
FORT WORTH
CITY OF FORT WORTH
FINAL PAYMENT REQUEST
Contract Name LIVE OAK PHASE 3A
Contract Limits
Project Type PAVING&ST LIGHT
City Project Numbers 101000
DOE Number 1000
Estimate Number 1 Payment Number 1 For Period Ending 4/10/2018
WD
City Secretary Contract Number Contract Time 6WD
Contract Date Days Charged to Date 186
Project Manager NA Contract is 100.00 Complete
Contractor GILCO CONTRACTING,INC.
6331 SOUTHWEST BLVD.
BENBROOK, TX 76132-1063
Inspectors OWEN / HOUSTON
Tuesday,April 10,2018 Page 1 of 4
City Project Numbers 101000 DOE Number 1000
Contract Name LIVE OAK PHASE 3A Estimate Number I
Contract Limits Payment Number I
Project Type PAVING&ST LIGHT For Period Ending 4/10/2018
Project Funding
PAVING
Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed
No. Quanity Total Quanity Total
---------------------------------------
1 9"CONC PVMT 1092 SY $52.90 $57,766.80 192 $10,156.80
2 6"CONC PVMT 9089 SY $34.75 $315,842.75 9089 $315,842.75
3 4"CONC SIDEWALK 4873 SF $5.50 $26,801.50 4873 $26,801.50
4 8"LIME TREATMENT 1147 SY $2.90 $3,326.30 1147 $3,326.30
5 6"LIME TREATMENT 9543 SY $2.80 $26,720.40 9543 $26,720.40
6 HYDRATED LIME 177 TN $160.00 $28,320.00 177 $28,320.00
7 BARRIER FREE RAMP 6 EA $2,000.00 $12,000.00 6 $12,000.00
8 BARRIER FREE RAMP 2 EA $2,000.00 $4,000.00 2 $4,000.00
9 BARRIER FREE RAMP 6 EA $2,000.00 $12,000.00 6 $12,000.00
10 24"SLD PVMT MARKING PAINT 56 LF $16.50 $924.00 56 $924.00
11 SKIP LANE PAVEMENT MARKINGS 364 LF $1.00 $364.00 364 $364.00
12 TURN LANE PAVEMENT MARKINGS 182 LF $2.50 $455.00 182 $455.00
13 END OF ROAD BARRICADE 7 EA $1,750.00 $12,250.00 7 $12,250.00
14 CONNECT TO EX STREET HEADER 83 LF $10.00 $830.00 83 $830.00
15 STD STREET HEADER 142 LF $15.00 $2,130.00 142 $2,130.00
16 REMOVE END OF ROAD BARRICADE 3 EA $500.00 $1,500.00 3 $1,500.00
----------------------------------------
Sub-Total of Previous Unit $505,230.75 $457,620.75
ST LIGHT&BONDS
Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed
No. Quanity Total Quanity Total
1 STREET SIGN 8 EA $500.00 $4,000.00 8 $4,000.00
2 PAYMENT&PERFORMANCE BONDS 1 LS $100.00 $100.00 1 $100.00
3 MAINTENANCE BOND I LS $8,500.00 $8,500.00 1 $8,500.00
Sub-Total of Previous Unit $12,600.00 $12,600.00
Tuesday,April 10,2018 Page 2 of 4
City Project Numbers 101000 DOE Number 1000
Contract Name LIVE OAK PHASE 3A Estimate Number I
Contract Limits Payment Number I
Project Type PAVING&ST LIGHT For Period Ending 4/10/2018
Project Funding
Contract Information Summary
Original Contract Amount $517,830.75
Change Orders
Total Contract Price $517,830.75
l " Total Cost of Work Completed $470,220.75
Date
Co tr ctor Less %Retained $0.00
c,�/ Net Earned $517,830.75
�_/
Date / 0v Earned This Period $517,830.75
Insp ction Sup isor
t-( -25_ 1$ Retainage This Period $0.00
Date Less Liquidated Damages
Proje t kanager
Days @ /Day $0.00
-V rfx-5- Date 2 Y LessPavement Deficiency $0.00
Asst. i tor/TP/W' Less Penalty $0.00
W Date 10/0 Less Previous Payment $0.00
Director ontracting Departm t Plus Material on Hand Less 15% $0.00
Balance Due This Payment $517,830.75
Tuesday,April 10,2018 Page 3 of
City Project Numbers 101000 DOE Number 1000
Contract Name LIVE OAK PHASE 3A Estimate Number I
Contract Limits Payment Number I
Project Type PAVING&ST LIGHT For Period Ending 4/10/2018
Project Funding
Project Manager NA City Secretary Contract Number
Inspectors OWEN / HOUSTON Contract Date
Contractor GILCO CONTRACTING,INC. Contract Time 60 WD
6331 SOUTHWEST BLVD. Days Charged to Date 186 WD
BENBROOK, TX 76132-1063 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 $470,220.75
Less %Retained $0.00
Net Earned $517,830.75
Earned This Period $517,830.75
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 $517,830.75
Tuesday,April 10,2018 Page 4 of 4
FORTWORTH rev 03/05/07
TRANSPORTATION& PUBLIC WORKS
FINAL STATEMENT OF CONTRACT TIME
FINAL STATEMENT NO,1
NAME OF PROJECT:Live Oak Phase 3A
PROJECT NO.: 101000 CONTRACTOR: Gilco Contracting,Inc
DOE NO. N/A
PERIOD FROM 10/09/17 TO: 04/12/18 FINAL INSPECTION DATE: 12-Apr-18
WORK ORDER EFFECTIVE 10/9/2017 CONTRACT TIME 60 O WD O CD
DAY OF DAYS REASON FOR DAYS DAY OF DAYS REASON FOR DAYS
MONTH CHARGED CREDITED MONTH CHARGED CREDITED
DURING DURING
1. 16.
2. 17.
3. 18.
4. 19.
5. 20.
6. 21.
7. 22.
8. 23.
9. 24.
10. 25.
11. 26.
12. 27.
13. 28•
14. 29.
15. 30.
31.
SAT,SUN, RAIN,TOO WET, UTILITIES DAYS TOTAL
&HOLIDAYS &TOO COLD RELOCATIONS OTHERS* CHARGED DAYS
THIS 0 0 0 0 186 186
PERIOD
PREVIOUS 0 0 0 0 0 0
PERIOD
TOTALS 0 0 0 0 186 186
TO DATE
*REMARKS
CONT CTOR DATE INSPE TOR DATE
ENGINEERING DEPARTMENT
� ' The City of Fort Worth• 1000 Throckmorton Street•Fort Worth,Thi 76012-6311
0
(817)392-7941 •Fax: (817)392-7845 �e )
FORTWORTHREV:8/20/16
TRANSPORTATION AND PUBLIC WORKS
PERFORMANCE EVALUATION OF CONTRACTOR
I) CONTRACTOR&PROJECT DATA
Name of Contractor Project Name
Gilco Contracting Live Oak Phase 3A
Inspector City Project Number
Gary Houston 101000
Construction Components Project Manager
❑ Water ❑ Waste Water ❑ Storm Drainage F1 Pavement Fred Ehia
Initial Contract Amount Project Difficulty
$517,830.75 O Simple O Routine O Complex
Final Contract Amount Date
$517,830.75 4/12/2018
II)PERFORMANCE EVALUATION
0-Inadequate 1-Deficient 2-Standard 3-Good 4-Excellent
ELEMENT WEIGHT(X) APPLICABLE(Y/N) RATING(0-4) MAX SCORE SCORE
1 Submission of Documents 2 Y 4 8 8
2 Public Notifications 5 Y 4 20 20
3 Plans on Site 5 Y 4 20 20
4 Field Supervision 15 Y 4 60 60
5 Work Performed 15 Y 4 60 60
6 Finished Product 15 Y 4 60 60
7 Job Site Safety 15 Y 4 60 60
8 Traffic Control Maintenance 15 Y 4 60 60
9 Daily Clean Up 5 Y 4 20 20
10 Citizen's Complaint Resolution 5 Y 4 20 20
11 Property Restoration 5 Y 4 20 20
12 After Hours Response 5 Y 4 20 20
13 Project Completion 5 Y 4 20 20
TOTAL ELEMENT SCORE(A) 448
BONUS POINTS(25 Maximum)(B)
TOTAL SCORE(TS) 448
III)CONTRACTOR'S RATING
Maximum Score(MS)=448 or sum of applicable element score maximums which= 448
Rating(ITS/MS]* 100%) 448 / 448 = 100%
Performance Category Excellent
<20%=Inadequate 20%to<40%=Deficient 40%to<60%=Standard 60%to<80%=Good >_80%=Excellent
Inspector's Comments(INCLUDING EXPLANATION OF BONUS POINTS AWARDED)
Inspector Signature Contractor Signature If
Inspector's Supervisor Signature
CONTRACTOR'S COMMENTS
TRANSPORTATION AND PUBLIC WORKS
The City of Fort Worth• 8851 Camp Bowie West Blvd.•Fort Worth,TX 76116•(817)392-8306
t
FORTWORTHREV:02/22/07
TRANSPORTATION AND PUBLIC WORKS
CONTRACTOR'S EVALUATION OF CITY
n PROJECT INFORMATION Date: 4/12/2018
Name of Contractor Project Name
Gilco Contracting Live Oak Phase 3A
DOE Inspector Project Manager
Gary Houston Fred Ehia
DOE Number Project Difficulty Type of Contract
101000 O Simple O Routine O Complex ❑ Water ❑ Waste Water ❑ Storm Drainage 0 Pavement
Initial Contract Amount Final Contract Amount
$517,830.75 $517,830.75
In PERFORMANCE EVALUATION
0-Inadequate 1 -Deficient 2-Standard 3-Good 4-Excellent
ELEMENT RATING ELEMENT RATING
(0-4) (0-4)
INSPECTION EVALUATION PLANS&SPECIFICATIONS
1 Availability of Inspector 1 Accuracy of Plans to Existing Conditions _
2 Knowledge of Inspector 2 Clarity&Sufficiency of Details
3 Accuracy of Measured Quantities 3 Applicability of Specifications
4 Display Of Professionalism 4 Accuracy of Plan Quantities
5 Citizen Complaint Resolution PROJECT MANAGER EVALUATION
6 Performance-Setting up Valve Crews,Labs 1 Knowledge And/Or Problem Resolution `(
ADMINISTRATION 2 Availability of Project Manager
1 Change Order Processing Time `� 3 Communication Lf
2 Timliness of Contractor Payments q 4 Resolution of Utility Conflicts
3 Bid Opening to Pre-Con Meeting Timeframe
M)COMMENTS&SIGNATURES
COMMENTS
Signature Contractor
c
Signature DOE Inspector
Signature DOE Inspector's Supervisor
INSPECTOR'S COMMENT
TRANSPORTATION AND PUBLIC WORKS
(D The City of Fort Worth•1000 Throckmorton Street'Fort Worth,TX 76012-6311
(817)392-7941 •Fax:(817)392-7845
GILCO CONTRACTING, INC.
TRANSMITTAL LETTER
PROJECT: Live Oak,Phase 3A
PROJECT NO.: 1234
DATE: April 11,2018
TO: City of Fort Worth
8851 Camp Bowie W.Blvd.
Fort Worth,Texas 76116
We transmit:
(X)Herewith ( )Under Separate cover via
For Your:
( )Approval ( )Distribution to parties
( )Review&Comment ( )Record
(X)Use ( )Execution
The following:
(X)Other ( ) Shop Drawing Prints
( ) Specifications ( ) Shop Drawing Reproducible
( )Bonds ( )Contract Documents
Copies Date Rev.No. Description
1 Final Paperwork&Consent of Surety
REMARKS:
COPIES TO: (with enclosures)
( ) BY: Rob Taylor
6331 Southwest Blvd. /Benbrook, Texas 76132
817/735-1600 ext. 316 Fax 817/735-1613
rob@gilcocontracting.com
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 Rob Taylor, Project
Coordinator of Gilco Contracting, Inc., 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;
Paving Improvements to serve: Live Oak Phase 3A
BY: Rob Taylor
Subscribed and sworn before me on this 11th of April , 2018.
MARY PANNELL _
NOCITY Public,$tate of Texas
��"'�'�',•�,:,°-.45
, . e Con,,,.Expires 10-19-2018
�,,"`,,oS" Notary I� alAA239 \�
ot�ary
,
Tarrant County, TX
April 11, 2018
City of Fort Worth
CFA Administration
1000 Throckmorton St.
Fort Worth, TX 76102
RE: Final Waiver of Lien; Paving Improvements to serve Live Oak, Phase 3A
City Project#101000
File No. W-2500
File No. X-24433
The purpose of this letter is to acknowledge that we have been paid in full by 351
Development, LLC for the public improvements constructed to serve Live Oak, Phase 3A
in Fort Worth, Texas. As a result, we hereby waive, release and relinquish all rights to
assert any claim or demand for lien in connection with this project.
Please feel free to contact me with any questions you may have.
Sincerely,
Gn
Rob Taylor
;71
Project Coordinator
6331 Southwest Blvd.
Benbrook,Texas 76132
Office: 817.735.1600
Fax: 817.735.1613
CONSENT OF OWNER ❑
SURETY COMPANY ARCHITECT ❑
CONTRACTOR ❑
TO FINAL PAYMENT SURETY ❑
Conforms with the American Institute of OTHER
Architects,AIA Document G707
Bond No 022058111
PROJECT:
(name, addreSS)Live Oak Phase 3A- Paving Improvements
Fort Worth TX
TO (Owner)
351 DEVELOPMENT, LLC AND CITY OF FORT ARCHITECT'S PROJECT N0:
WORTH CONTRACT FOR:
9800 Hillwood Parkway,Suite 250 Live Oak Phase 3A-Paving Improvements
Fort Worth TX 76177 CONTRACT DATE:
CONTRACTOR:GILCO CONTRACTING, 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 (here insert name and address of Contractor)
GILCO CONTRACTING, 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)
351 DEVELOPMENT, LLC AND CITY OF FORT WORTH
9800 Hillwood Parkway, Suite 250
Fort Worth TX 76177 , OWNER,
as set forth in the said Surety Company's bond.
IN WITNESS, WHEREOF,
the Surety Company has hereunto set its hand this 11th day of April, 2018
LIBERTY MUTUAL INSURANCE COMPANY
Sure Company
Atte sC:V. eL ars"
hal
Signa re 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
ONE PAGE
THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS PRINTED ON RED BACKGROUND.
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.
Certificate No.7988831
Liberty Mutual Insurance Company
The Ohio Casualty Insurance Company 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,
Robbi Morales;Don E Cornell;Sophinie Hunter;V DeLene Marshall;Tina McEwan•Ricardo J.Reyna Kelly A.Westbrook
all of the city of Dallas state of T.X 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 the Companies have been affixed
thereto this 24th day of January 2018 >+
to
I ; RAS Iso h'yr The Ohio Casualty Insurance Company to
N
Liberty Mutual Insurance Company m
a i919 n 1912 N 1991
c i 5 WestAmerican Insurance Company
Ui
N
4.1 e STATE OF PENNSYLVANIA ss David M.Care ,Assistant Secretary
COUNTY OF MONTGOMERY — o
c
NOn this 24th day of January 2018 before me personally appeared David M.Carey,who acknowledged himself to be the Assistant Secretary of Liberty Mutual Insurance v I—
v d 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 >
W
p 2 therein contained by signing on behalf of the corporations by himself as a duly authorized officer.
N > 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. 0 CL
+•r p, PAgr COMMONWEALTH OF PENNSYLVANIA Q M
�Po ort We Flt # Notarial Seal 04
Y 1 Teresa Pastella,Notary Public By: --- L'a
O ` OF Upper MerionTwp.,Montgomery County Teresa Pastella,Notary Public (D
°� w #My Commission Expires March 28,2021 3
_ L '-may�P�,[.�
r o yOr'QRY 4�qV .Member,Pennsylvania Association of Notaries 0 E
Y�_ a
CThis 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 Ur c
Insurance Company,and West American Insurance Company which resolutions are now in full force and effect reading as follows: ' ..
Os
dARTICLE IV—OFFICERS—Section 12.Power of Attorney.Any officer or other official of the Corporation authorized for that purpose in writing by the Chairman or the President,and subject O r-
4)
4; 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, �+y
O S 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
E r powers of attorney,shall 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 d
p executed,such instruments shall be as binding as if signed by the President and attested to by the Secretary.Any power or authority granted to any representative or attorney-in-fact under >o
the 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. L d
+,N
C 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, oQ
L and subject to such limitations as the chairman or the president may prescribe,shall appoint such attorneys-in-fact,as may be necessary to act in behalf of the Company to make,execute, L M
o 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 o 0
Z v 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
co
executed such instruments shall be as binding as if signed by the president and attested by the secretary. o
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-m- ~
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.
1, 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. `I�
IN TESTIMONY WHEREOF,I have hereunto set my hand and affixed the seals of said Companies this 'Im day of r I 20 .
�gv1Ns� ytNSUR Nti`sury _ )�','�/}
p 1979 n Q By.
o r 1912 r 1991 a
a a Renee C.Llew ssistant Secretary
s
�ryharna5�4�-A� y9i)'�ssntrnis���`' y Nrnaua �.
128 of 400
LMS 12873 022017
Liberty
Mutual.
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 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, Seguroacerca sde eTexas companiasarcoberturas, dere hosinformacion
o
coverages, rights or complaints at ,
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 (111-1A) de Texas Consumer Protection (111-1A)
P. O. Box 149091 P. O. Box 149091
Austin, TX 78714-9091 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: ConsumerProtection(a)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 eel ag
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: 11
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 10/15