HomeMy WebLinkAboutContract 53049-FP4 City Secretary 53049 -FP4
Contract No.
FORTWORTH., Date Received Oct 30,2020
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: VENTANA PHASE 4
City Project No.: 102239
Improvement Type(s): ❑ Paving ® Drainage ❑ Street Lights ❑ Traffic Signals
Original Contract Price: $1,141,608.70
Amount of Approved Change Order(s):
Revised Contract Amount:
Total Cost of Work Complete: $1,141,608.70
Zi?#/w cafto#t
Daniel Cannon(Oct 29,202013:14 CDT) OCt 29,2020
Contractor Date
Project Manager
Title
KCK Utility Construction, Inc
Company Name
Ramon Chavez(Oct 2, 13:15CDT) Oct 29,2020
Project Inspector Date
Patrick a ley(Oc 9,202014:15CDT) Oct 29,2020
Project Manager Date
Laurie Lewis
Laurie Lewis(Oct 29,202015:49 CDT) Oct 29,2020
CFA Manager Date
Dana Burghdoff(Oct 29,20 7:33CDT Oct29,2020
Asst. City Manager Date
OFFICIAL RECORD
CITY SECRETARY Page 1 of 2
FT.WORTH, TX
Notice of Project Completion
Project Name:VENTANA PHASE 4
City Project No.: 102239
City's Attachments
Final Pay Estimate
Change Order(s): ❑ Yes ® N/A
Contractor's Attachments
Affidavit of Bills Paid
Consent of Surety
Statement of Contract Time
Contract Time: 100 CD Days Charged: 323
Work Start Date: 11/20/2019 Work Complete Date: 7/1/2020
Page 2of2
FORT WORTH
CITY OF FORT WORTH
FINAL PAYMENT REQUEST
Contract Name VENTANA PHASE 4
Contract Limits
Project Type STORM DRAIN
City Project Numbers 102239
DOE Number 2239
Estimate Number 1 Payment Number 1 For Period Ending 10/28/2020
CD
City Secretary Contract Number Contract Time 1WD
Contract Date Days Charged to Date 323
Project Manager NA Contract is 100.00 Complete
Contractor KCK UTILITY CONSTRUCTION
103 N.ALLEN DRIVE
ALLEN, TX 75013
Inspectors OWEN/ CHAVEZ
Wednesday,October 28,2020 Page 1 of 5
City Project Numbers 102239 DOE Number 2239
Contract Name VENTANA PHASE 4 Estimate Number 1
Contract Limits Payment Number 1
Project Type STORM DRAIN For Period Ending 10/28/2020
Project Funding
STORM DRAIN
Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed
No. Quanity Total Quanity Total
---------------------------------------
1 REMOVE EXISTING RIP RAP 338 SY $16.00 $5,408.00 338 $5,408.00
2 REMOVE PROPOSED 24"STORM LINE 15 LF $20.00 $300.00 15 $300.00
3 REMOVE EXISTING TXDOT CH-FW-0 1 EA $1,300.00 $1,300.00 1 $1,300.00
WINGWALL
4 REMOVE PROPOSED 24"SLOPED END 1 EA $1,300.00 $1,300.00 1 $1,300.00
HEADWALL
5 LARGE STONE RIPRAP,DRY 794 SY $99.00 $78,606.00 794 $78,606.00
6 POST CCTV INSPECTION 4249 LF $2.20 $9,347.80 4249 $9,347.80
7 TRENCH SAFETY 4249 LF $0.10 $424.90 4249 $424.90
8 CONCRETE COLLAR 1 EA $450.00 $450.00 1 $450.00
9 18"RCP 140 LF $47.00 $6,580.00 140 $6,580.00
10 21"RCP 891 LF $52.00 $46,332.00 891 $46,332.00
11 24"RCP 1725 LF $60.00 $103,500.00 1725 $103,500.00
12 30"RCP 10 LF $77.00 $770.00 10 $770.00
13 36"RCP 100 LF $97.00 $9,700.00 100 $9,700.00
14 5'X4'BOX CULVERT 825 LF $235.00 $193,875.00 825 $193,875.00
15 2-6'X4'BOX CULVERT 127 LF $604.00 $76,708.00 127 $76,708.00
16 2-8'X4'BOX CULVERT 152 LF $846.00 $128,592.00 152 $128,592.00
17 4'STORM JUNCTION BOX 8 EA $6,600.00 $52,800.00 8 $52,800.00
18 8'X5'STORM JUNCTION BOX 1 EA $7,565.00 $7,565.00 1 $7,565.00
19 8'X8'STORM JUNCTION BOX 3 EA $8,550.00 $25,650.00 3 $25,650.00
20 4'STACKED MANHOLE 1 EA $6,600.00 $6,600.00 1 $6,600.00
21 10'CURB INLET 20 EA $4,840.00 $96,800.00 20 $96,800.00
22 15'CURB INLET 10 EA $5,720.00 $57,200.00 10 $57,200.00
23 20'CURB INLET 2 EA $6,600.00 $13,200.00 2 $13,200.00
24 4'DROP(AREA)INLET 1 EA $4,200.00 $4,200.00 1 $4,200.00
25 4'GRATE INLET 1 EA $4,620.00 $4,620.00 1 $4,620.00
26 5'X4'TXDOT 2 EA $20,570.00 $41,140.00 2 $41,140.00
27 12'X4'TXDOT 2 EA $29,100.00 $58,200.00 2 $58,200.00
28 16'X4'TXDOT 2 EA $36,050.00 $72,100.00 2 $72,100.00
29 21"SLOPED END HEADWALL 2 EA $2,420.00 $4,840.00 2 $4,840.00
30 24"SLOPED END HEADWALL 4 EA $2,640.00 $10,560.00 4 $10,560.00
Wednesday,October 28,2020 Page 2 of 5
City Project Numbers 102239 DOE Number 2239
Contract Name VENTANA PHASE 4 Estimate Number 1
Contract Limits Payment Number 1
Project Type STORM DRAIN For Period Ending 10/28/2020
Project Funding
31 24"CH-FW-45 HEADWALL 1 EA $2,420.00 $2,420.00 1 $2,420.00
32 36"SLOPED END HEADWALL 1 EA $3,520.00 $3,520.00 1 $3,520.00
33 CONNECT TO EXISTING STORM RCP 2 EA $1,000.00 $2,000.00 2 $2,000.00
34 SEEDING,BROADCAST 1 LS $15,000.00 $15,000.00 1 $15,000.00
Sub-Total of Previous Unit $1,141,608.70 $1,141,608.70
Wednesday,October 28,2020 Page 3 of 5
City Project Numbers 102239 DOE Number 2239
Contract Name VENTANA PHASE 4 Estimate Number 1
Contract Limits Payment Number 1
Project Type STORM DRAIN For Period Ending 10/28/2020
Project Funding
Contract Information Summary
Original Contract Amount $1,141,608.70
Change Orders
Total Contract Price $1,141,608.70
Total Cost of Work Completed $1,141,608.70
Less %Retained $0.00
Net Earned $1,141,608.70
Earned This Period $1,141,608.70
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 $1,141,608.70
Wednesday,October 28,2020 Page 4 of 5
City Project Numbers 102239 DOE Number 2239
Contract Name VENTANA PHASE 4 Estimate Number 1
Contract Limits Payment Number 1
Project Type STORM DRAIN For Period Ending 10/28/2020
Project Funding
Project Manager NA City Secretary Contract Number
Inspectors OWEN/ CHAVEZ Contract Date
Contractor KCK UTILITY CONSTRUCTION Contract Time 100 CD
103 N.ALLEN DRIVE Days Charged to Date 323 CD
ALLEN, TX 75013 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 $1,141,608.70
Less %Retained $0.00
Net Earned $1,141,608.70
Earned This Period $1,141,608.70
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 $1,141,608.70
Wednesday,October 28,2020 Page 5 of 5
FORTWORTH.
TRANSPORTATION AND PUBLIC WORKS
October 19, 2020
KCK Utility Construction Inc.
1024 S. Greenville Ave.,Suite 100
Allen,TX 75002
RE: Acceptance Letter
Project Name:Ventana Phase 4
Project Type: Developer
City Project No.: 102239
To Whom It May Concern:
On October 7, 2020 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 October 14, 2020. 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 October 14, 2020, 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 a ley(oct49,202014:15 CDT)
Patrick Buckley, Project Manager
Cc: Ramon Chavez, Inspector
Billy Owen, Inspection Supervisor
Joseph Rogers,Senior Inspector
Victor Tornero, Program Manager
UA Engineering, Consultant
KCK Utility Construction Inc., Contractor
Green Brick, Developer
File
E-Mail: TPW_Acceptance@fortworthtexas.gov
Rev.8/20/19
KCK U'T I L,I T'Y
G(D"S'TF U4=0' rIaH
1 024 G. GREENVILL-E AVE., SUITE 100
ALLEN, TEXAS 75002
(214) 547-91 52 OFF-(21 4) 547-9 1 63 FAX
BILLS PAID AFFIDAVIT
STATE OF TEXAS
COUNTY OF COLLIN
BEFORE ME, the undersigned authority, on this day personally appeared Jerry Covington,Jr., known to me to
be a credible person and officer of KCK Utility Construction., Inc., a Texas Corporation(hereinafter called
"Contractor"), and who, being duly sworn, upon his oath declares and acknowledges as follows:
1. I am the duly authorized agent for the said Contractor, which has authorized me to make this affidavit, and
all of the recitations herein are true and correct.
2. Pursuant to an agreement-dated 6-18-2019 between KCK Utility Construction,Inc.,and GRBK
EDGEWOOD,LLC, has supplied materials and performed labor in connection with the construction of
improvements upon certain real property owned by the Owner in Tarrant County,Texas. Said
improvements are more particularly described as Water,Sanitary Sewer and Storm Drainage
improvements for Ventana Phase 4(the "Improvements").
3. Contractor has actual knowledge that all bills owed by Contractor to others for materials supplied or labor
performed in connection with the Improvements have been fully paid and satisfied except for contractual
rtainage. Contractor does further warrant that should any claim or lien be filed for material supplied or
labor performed by virtue of Contractor's participation in the construction of said Improvement,Contractor
will immediately furnish a bond pursuant to Texas Property Code, Sections 53.236 through 53.238, for
release of each such lien, and obtain settlement of any such liens and furnish Owner written full release of
such liens. Should Contractor be unable to obtain such release, Contractor agrees to fully indemnify and
hold harmless the Owner for any and all costs they may incur by reason of such lien.
EXECUTED this 13`4 day of October, 2020.
KCK UTILITY CONSTRUCTION, INC.
By:
Name: J ry Co on
Title: President
SUBSCRIBED AND SWORN TO BEFORE ME by the said Jerry Covington,Jr., on this the 1 P day of
October, 2020,to certify which witness my hand and seal of office.
I
ESJAM:ESDOUGLAS WILSON
y 10#124492049 ota lic in and for the State of Tcxasmmission Expires
rCl 22. 2023
OD b2 19-t
MATNTENANCH BOND
Page 1 of
Bond No.2296056
l SECTION 00 62 19
2 MAINTENANCE BOND
3
4 THE STATE OF TEXAS §
5 § KNOW ALL BY THESE PRESENTS:
6 COUNTY OF TARRANT §
7 That we,KCK Utility Construction, known as"Principal"herein and
8 North American Specialty Insurance Company ,a corporate surety(sureties, if more than
9 one)duly authorized to do business in the State of Texas,known as"Surety"herein(whether one
10 or more),are held and firmly bound unto the Developer,GRBK EDGEWOOD, LLC,authorized
11 to do business in Texas("Developer")and the City of Fort Worth,a Texas municipal corporation
Two Million,Six Hundred Thirty-Seven
12 ("City"),in the sum of Thousand Fifty-Three&10/100 Dollars
13 ($ 2,637,053.10 },lawful money of the United States,to be paid in Fort Worth,
14 Tarrant County,Texas,for payment of which sum well and truly be made jointly unto the
15 Developer and the City as dual obligees and their successors,we bind ourselves, our heirs,
16 executors,administrators,successors and assigns,jointly and severally, firmly by these presents.
17
18 WHEREAS, Developer and City have entered into an Agreement for the construction of
19 community facilities in the City of Fort Worth by and through a Community Facilities
20 Agreement,CFA Number CFA 19-0105;and
21 WHEREAS,the Principal has entered into a certain written contract with the Developer
22 awarded the day of ,20_,which Contract is
23 hereby referred to and a made part hereof for all purposes as if fully set forth herein,to furnish all
24 materials,equipment labor and other accessories as defined by law, in the prosecution of the
25 Work,including any Work resulting from a duly authorized Change Order(collectively herein,
26 the"Work")as provided for in said Contract and designated as ventana, Phase 4;and
27
28 WHEREAS,Principal binds itself to use such materials and to so construct the Work in
29 accordance with the plans,specifications and Contract Documents that the Work is and will
30 remain free from defects in materials or workmanship for and during the period of two(2)years
31 after the date of Final Acceptance of the Work by the City("Maintenance Period"); and
32
CITY OF FORT WORTH Ventana,Phase 4
STANDARD CITY CONDITIONS—DEVELOPER AWARDED PROJECTS CAN#102239
Revised January 31,2012
006219-2
MAINTENANCE BOND
Page 2 of 3
1 WHEREAS,Principal binds itself to repair or reconstruct the Work in whole or in part
2 upon receiving notice from the Developer and/or City of the need thereof at any time within the
3 Maintenance Period.
4
5 NOW THEREFORE, the condition of this obligation is such that if Principal shall
6 remedy any defective Work,for which timely notice was provided by Developer or City,to a
7 completion satisfactory to the City,then this obligation shall become null and void;otherwise to
8 remain in full farce and effect.
9
10 PROVIDED,HOWEVER, if Principal shall fail so to repair or reconstruct any timely
11 noticed defective Work,it is agreed that the Developer or City may cause any and all such
12 defective Work to be repaired and/or reconstructed with all associated costs thereof being borne
13 by the Principal and the Surety under this Maintenance Bond;and
14
15 PROVIDED FURTHER,that if any legal action be fled on this Bond,venue shall lie in
16 Tarrant County,Texas or the United States District Court for the Northern District of Texas,Fort
17 Worth Division;and
l8
19 PROVIDED FURTHER,that this obligation shall be continuous in nature and
20 successive recoveries may be had hereon for successive breaches.
21
22
23
CITY OF FORT WORTH Ventana,Phase 4
STANDARD CITY CONDITIONS—DEVELOPER AWARDED PROJECTS CPN#102239
Revised January 31,2012
006219-3
MAINTENANCE BOND
Page 3 or 3
l IN WITNESS WI•IEREOF, the Principal and the Surety have each SIGNED and S13ALED this
2 instrument by duly authorized agents and officers on this the —day of
3 , 20
4
5 PRINCIPAL.:
6 KCK Utility CaaMI-LIC lan,Inc.
7 _.
8
9 BY:
to Signature
11 ATTEST:
12
13 _
14 (Principal)Secretary _ Name and Tit le
15
16 Address:—1�29� ticuYiilt�dtis uuc.SttillglL--
17 Allcu,TX 75002 _
18
19
20 Witness as to Principal
2 t SURETY:
22 North Amcrk:M)Stiacia ly lasurance Company
23
24
25 BY
26 Signature
27
28 Andrea Rose Crawfurd,Ataorney-in-Fact
29 ATTEST: Name and Tide
30 .y1 -% /
31 yV��. j •.`•t`�• -� w Address: 1200 Maio Slrect.suilc 800_
32 ( ur ty)Secretary TK¢msns City,MO 64105
33 ---
34
35 Witness as to Surety Teleplionc Number: 913-676.5200
36 --
37 *Note: if signed by an officer of the Surety Company, there must be on file a certified extract
38 from the by-laws showing that this person has authority to sign such obligation, If
39 Surety's physical address is different from its mailing address, both must be provided.
40
41 The date of the bond shall not be prior to the date the Contract is awarded.
42
CITY OF FORE'V'OR'1]1 Vemansa,Phase 4
S'l'ANDARD CITY CONDITIONS—DEVELOPER AWARDED PROJECTS CPN N102239
Revised Janutaty 31,2012
SWISS RE CORPORATE SOLurIONS
NORTH AMERICAN SPECIALTY INSURANCE COMPANY
WASHINGTON INTERNATIONAL INSURANCE COMPANY
WESTPORT INSURANCE CORPORATION GENERAL POWER OF A'1"rORNEY
KNOW ALL MEN BY II MS]."PREiSIiNTS,'I'f IAT North American Specialty Insurance Company,it corporation duly organized and existing under
laws of the State of New I lampshire,and having its principal office in the City of Kansas City,Missouri and Washington International Insurance
Company it corporation organized and csisling under the laws of the State ofNew I lanipshire and having its principal oflice in the City of Kansas
City,Missouri,and Westport Insurance Corporation.or'anl%cd Under the laws ofthe Statc of Missouri,and having its principal office in the City of
Kansas City,Missouri does hereby make,constitute anf ilppoint:
SAMMY JOF MULLIS,JR.,JOHN WILLIAM NEWBY,CHERI LYNN 1RBY,MICI[AF.L L.TULLIS,SANDRA LI-'F RONFY,DEBRA LET.MOON,ANDRFA ROSE CRAWFORD,
MARY JO%AKRZtFWSKI,JAMI:S 11.ROOERS,JR.,'I'ROY RUSSI?Lt.KIIY,LINDA uIIC118LL1i S"I'AE.11RIi.CHKIS'1'(H'IlEilt C•ARI. WND11liRG amIJOSIMA 1).l'Rrr3'JOINTLY OR SEVERALLY
Its true and lawful Atlorney(s)-in-Fact,to make,exceufc,seal and deliver,for and on its bell a]fand as its acl and deed,bonds or other writings
obligatory 11n[lie nature ol'a bond oil behalf of each of said Companies,as Surely,oil contracts of suretyship as are or may be required or perlllllled by
law,regulation,contract or otherwise,provided that no bond or undertaking or contract rn'sitrc(yship executed under this authority shall exceed the
amount ol': TWO 1IUNDRL=D MILLION($200,000,000.00)DOLLARS
']'his Power of Attorncy is granted and is signed by facsimile tender and by the authority of the hollowing Resolutions adopted by the Bmirds of
Directors or North American Specialty Insurance Company and Washington International Insurance Company at meetings duly called and held
on March 24,2000 and Westport Insurance Corporation by written consent of its Eixeculivo Committee dated July 18,2011,
"RESOLVED,that any two of the President,any Senior Vice['resident,any Vice President,any Assistant Vice President,
the Secretary or any Assistant Secretary be,and each or any of 1hcm hereby is authorized to execute a Power of Attorney qualifying the attorney nailed
in the given Power of Attorncy to execute on behalfof the Company bonds,undertakings and all contracts of surety,and that each or any of them
hereby is authorized to attest to the execution of any such Power of Attorney and to attach therein the seal of the Company, and it is
FUIU 1 IFR RESOLV1iD,that the signature of such officers and the seal of the Company may be affixed to any such Power of Attorney or to any
certificate relating thereto by facsimile,and any such Power of Attorney or certificate bearing such facsimile signatures or lausinlile still shall be
binding upon the Company when so affixed and in the future with regard to any bond,undertaking or contract of surety to which it is attaehed."
¢11G11AL17Yjl//!/�/ �a ?liONfur �� kt� �% '2iElttlL?
"'Q'G,,., Hs//� �Ci oAPo l ysg ( t�J._...... }L...... "
b h:•G Rqj.I By / �C+ C 'W
G �'y j -0 L�r�L fi` W S(cr.•n .,er ersnn.,color oec nesr e11u ostngmu menni Mom nsurance Compnny �..• ? �T
r SEAL :O`• -e: y : &senior�'icr I'rrsiden,ur NarUr Amnricun Slteel.Jiy Insurance Company 4: � •r�, ,7�,
W%'L 1973 yri m a tr'J •ns$ &seeeier Yire Presideist of 1Yrsgwrl Lrxu rmiec Cnrparnlinu ] ,
Woo t11ke A,llo.Stnlur Vice I'Mident of iYo�in€euu tmanunimmi iusunurce Cam ixn k�•'
/llfllll111515 »mnyiet„uns'�' ] Y 1b
&Seutor Vice President ur\nrm Ameriuno Specially Insurance Company lJi3lkllYsf
&Senior Vice Presidem or Wcsy,arl huuntace Corporation
IN WH NESS W[IERtSOF,North American Specialty Insurance Company,Washington International Insuraticc Complllly and Westport
Insurance Corporation have caused their official seals to be hereunto affixed.and these presents to be signed by their authorized ollicers this-
this 3rd day of_ September ,20 19
North American Specialty Insurance Company
Washington I rlternational Insurance Company
State of Illinois Wcstllort Insurance Corporation
County of Cook ss:
On this 3rd day of September 20 19,belbre inc,it Notary Public personally appeared_ Stcvcn P.Anderson ,Senior Vice Presidem of
Washington Inicrflational Insurance Company and Senior Vice President ofNorih American Specialty Insurance Company and Senior Vice]'resident of
Westport Insurance Corporation and Michael A. Ito Senior Vice President of Washington International lttsuritnce Company and Senor Vice]'resident
of-North American Specialty Insurance Company and Senior Vice President of Westport Insurance Corporation, personally known to inc,who
being by me duly sworn,acknowledged Ilia(they signed the above Power of Attorncy as officers of anti acknolvlcdged said instrument to be the
voluntary act and deed of their respective companies.
OFF-10M.SIAL
m KENNY
N:,:ary••^ul:iir-Slat:,u!IIGa+:: ''---- -..__.--....-.-.--
h41LuM"Mivn:opir^ '
�zro�sozl M.Kenny,Nolary Public
I, Jeffrey 0oldber r , the duly elected Vice President and Assistant Secretary ol'North American Specialty Insurance Company,Washington
International Insurance Company and Westport Insurance Corporation do hereby ecrtily that the above and lilrcgoing is a true and correct copy of a
Power ol'Attorney given by said North American Specialty Insurance Company,Washington International Insurance Company and Westport Insurance
Corporation which is still in full force and Oka
IN WI'IT]ESS WI[]iRl;Ol',[have set illy hand and affixed the seals Of the Companies this_day of ,20
Jea'ruY CJald11ar.Vice picsiduni&ABsiBlant Secretory ar wkoioainu Inlcmational lnsomrs u Company&
Xnnh:5uswrem,Rpuciahy Insurnnc.•Company&Vice Yresnlom ,Assiv:nn Secretary of We;tpmt Insurance C•ogmmlion
North American Specialty Insurance Company
Washington International Insurance Company
Westport Insurance Corporation
TEXAS CLAIMS INFORMATION
IMPORTANT NOTICE ADVISO IMPORTANTE
In order to obtain information or make a complaint: Para obtener informacion o para someter un queja:
You may contact Jeffrey Goldberg,Vice President Puede comunicarse con Jeffrey Goldberg,Vice
- Claims at 1-800-338-0753 President- Claims,al 1-800-338-0753
You may call Washington International Insurance Usted puede Ilamr at numeeo de telefono gratis de
Company and/or North American Specialty Insurance Washington International Insurance Company and/or
Company's and/or Westport Insurance Corporation North American Specialty Insurance Company's and/or
toll-free number for information or to make a Westport Insurance Corporation para informacion o
complaint at: para someter una queja al.
1-800-33 8-07 53 1-800-3 3 8-07 53
You may also write to Washington International Usted tambien puede escribir a Washington
Insurance Company and/or North American Specialty International Insurance Company and/or North
Insurance Company and/or Westport Insurance American Specialty Insurance Company and/or
Corporation at the following address: Westport Insurance Corporation al:
1450 American Lane 1450 American Lane
Suite 1100 Suite 1100
Schaumburg,IL 60173 Schaumburg,IL 60173
You may contact the Texas Department of Insurance Puede escribir al Departmento de Seguros de Texas
to obtain information on companies, coverages, para obtener information acerca de companias,
rights or complaints at: coberturas,derechos o quejas al:
1-800-252-3439 1-800-252-3439
You may write the Texas Department of Insurance: Puede escribir al Departmento de Seguros de Texas:
P.O. Box 149104 P.O. Box 149104
Austin,TX 78714-9104 Austin,TX 78714-9104
Fax: (512)475-1771 Fax: 1512)475-1771
Web: httn://www_jdj,srate.tx.us Web:
Email:ConsumerProtection@tdi.state.tx.us Email:Cons umerProtection@tdi.state.tx.us
PREMIUM OR CLAIM DISPUTES: DISPUTAS SOBRE PRIMAS 0 RECLAMOS:
Should you have a dispute concerning your premium Si tiene una disputa concerniente a su prima o a un
or about a claim you should first contact the reclamo,debe comunicarse con el Washington
Washington International Insurance Company and/or International Insurance Company and/or North
North American Specialty Insurance Company and/or American Specialty Insurance Company and/or
Westport Insurance Corporation. If the dispute is not Westport Insurance Corporation primero. Si no se
resolved,you may contact the Texas Department of resuelve la disputa, puede entonces comunicarse
Insurance. con el Departmento de Seguros de Texas.
ATTACH THIS NOTICE TO YOUR POLICY: UNA ESTE AVISO A SU POLIZA
This notice is for information only and does not Este aviso es solo para proposito de infromacion y no
become a part or condition of the attached se converte en parte o condition del documento
document. adjunto.