HomeMy WebLinkAboutContract 54805-FP2 City Secretary 54805 FP2
Contract No.
FORTWORTH,. Date Received Sep 14,2021
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: TRAILS OF ELIZABETH CREEK PHASE 8
City Project No.: 102608
Improvement Type(s): Water ❑x Sewer ❑x
Original Contract Price: $647,810.90
Amount of Approved Change Order(s): -$2,360.70
Revised Contract Amount: $645,450.20
Total Cost of Work Complete: $645,450.20
AGbel-t G�g�t�et se�1 l0 2021
Albert Grantges(Sep 10,All 14:16 CDT) p
Contractor Date
Vice President
Title
Burnsco Construction,Inc.
Company Name
a.—NQ S 10 2021
Jess e davis(Sep 10,202115:36 CDT) p
Project Inspector Date
01,71 Taa-Fan P.E.
KhalJaafari P.E.(Sep 10,202119:38 CDT) Sep 10,2021
Project Manager Date
7e&1aA1- Sep 13,2021
CFA Man a r Date
Dana Burghdoff(Sep 13,20 22:02 CDT Sep 13,2021
Asst. City Manager Date
OFFICIAL RECORD
CITY SECRETARY
FT.WORTH, TX
Notice of Project Completion
Project Name: TRAILS OF ELIZABETH CREEK PHASE 8
City Project No.: 102608
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 v ,;
Statement of Contract Time
Contract Time: 150 WD Days Charged: 141
Work Start Date: 12/21/2020 Work Complete Date: 8/30/2021
Completed number of Soil Lab Test: 755
Completed number of Water Test: 12
Page 2of2
FORT WORTH
CITY OF FORT WORTH
FINAL PAYMENT REQUEST
Contract Name TRAILS OF ELIZABETH CREEK PHASE 8
Contract Limits
Project Type WATER&SEWER
City Project Numbers 102608
DOE Number 2608
Estimate Number 1 Payment Number 1 For Period Ending 9/10/2021
WD
City Secretary Contract Number Contract Time 7WD
Contract Date Days Charged to Date 141
Project Manager NA
Contract is 100.00 Complete
Contractor BURNSCO CONSTRUCTION,INC.
6331 SOUTHWEST BLVD
FORT WORTH, TX 76132
Inspectors GLOVER/ DAVIS
Friday,September 10,2021 Page 1 of 4
City Project Numbers 102608 DOE Number 2608
Contract Name TRAILS OF ELIZABETH CREEK PHASE 8 Estimate Number 1
Contract Limits Payment Number 1
Project Type WATER&SEWER For Period Ending 9/10/2021
Project Funding
WATER
Item Estimated Estimated Completed Completed
Description of Items Unit Unit Cost
No. Quanity Total Quanity Total
---------------------------------------
1 8"WATER PIPE CO#2 5552 LF $24.00 $133,248.00 5552 $133,248.00
2 8"GATE VALVE 11 EA $1,380.00 $15,180.00 11 $15,180.00
3 FIRE HYDRANT 3 EA $4,500.00 $13,500.00 3 $13,500.00
4 DUCTILE IRON WATER FITTINGS 1.38 TN $5,000.00 $6,900.00 1.38 $6,900.00
W/RESTRAINT
5 1"WATER SERVICE CO#1 158 EA $887.00 $140,146.00 158 $140,146.00
6 TRENCH SAFETY CO#2 5552 LF $0.10 $555.20 5552 $555.20
7 CONNECTION TO EXISTING 4"-12"WATER 5 EA $700.00 $3,500.00 5 $3,500.00
MAIN
8 8"WATER LOWERING 14 EA $4,100.00 $57,400.00 14 $57,400.00
Sub-Total of Previous Unit $370,429.20 $370,429.20
--------------------------------------
SEWER
Item Estimated Estimated Completed Completed
Description of Items Unit Unit Cost
No. Quanity Total Quanity Total
1 8"SEWER PIPE CO#1 3896 LF $29.00 $112,984.00 3896 $112,984.00
2 4"SEWER SERVICE CO#1 128 EA $680.00 $87,040.00 128 $87,040.00
3 POST CCTV INSPECTION 3995 LF $3.60 $14,382.00 3995 $14,382.00
4 MANHOLE ADJUSTMENT 6 EA $470.00 $2,820.00 6 $2,820.00
5 T MANHOLE 15 EA $2,700.00 $40,500.00 15 $40,500.00
6 8"SEWER PIPE,CSS BACKFILL 220 LF $30.00 $6,600.00 220 $6,600.00
7 MANHOLE VACUUM TESTING 15 EA $120.00 $1,800.00 15 $1,800.00
8 TRENCH SAFETY 3995 LF $1.00 $3,995.00 3995 $3,995.00
9 CONNECT TO EXISTING SEWER MAIN 7 EA $700.00 $4,900.00 7 $4,900.00
Sub-Total of Previous Unit $275,021.00 $275,021.00
Friday,September 10,2021 Page 2 of 4
City Project Numbers 102608 DOE Number 2608
Contract Name TRAILS OF ELIZABETH CREEK PHASE 8 Estimate Number 1
Contract Limits Payment Number 1
Project Type WATER&SEWER For Period Ending 9/10/2021
Project Funding
Contract Information Summary
Original Contract Amount $647,810.90
Change Orders
Change Order Number 1 ($5,325.00)
Change Order Number 2 $2,964.30
Total Contract Price $645,450.20
Total Cost of Work Completed $645,450.20
Less %Retained $0.00
Net Earned $645,450.00
Earned This Period $645,450.00
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 $645,450.00
Friday,September 10,2021 Page 3 of 4
City Project Numbers 102608 DOE Number 2608
Contract Name TRAILS OF ELIZABETH CREEK PHASE 8 Estimate Number 1
Contract Limits Payment Number 1
Project Type WATER&SEWER For Period Ending 9/10/2021
Project Funding
Project Manager NA City Secretary Contract Number
Inspectors GLOVER/ DAVIS Contract Date
Contractor BURNSCO CONSTRUCTION,INC. Contract Time 70 WD
6331 SOUTHWEST BLVD Days Charged to Date 141 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 $645,450.20
Less %Retained $0.00
Net Earned $645,450.00
Earned This Period $645,450.00
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 $645,450.00
Friday,September 10,2021 Page 4 of 4
o k ® /
7 §
_
§
0
( /
E §
� �
CV) §
04
. ,
ou
2 CD
ƒ / _
}LAJ
} k _
Lu ° b k
7 ,
� � 3 m
uj
>-100
\ \ \
/ pp o
a = /
/ � / 0
m/
Cl)
m _
L 00 k
$ 2 ) $ & 04
o e IL G
/ _ \ / _
E _ #
\
w
/ { = zz 7
E e \ yy 3
/ � � \ \ co
E ( ` CN
< 4 G § cq
\ _ -
/ 00 % k
E J ) 5 \ _
o a � % 3
_ \ . ° _ ,
§ �\
e tj 2a E
N } ( E { »
a 2 � » ! _
5-1 $ c j -
y . \ @ } \ _ /
/ / / G 3 K m
e 4 a r z z k I / ® ® ^ ® j
e z
\ e )
# # j ° \ ) e / (
\
3> t < Zm Z
\ \ / § §` §
Re z \ \ }/ !( (
z@j cl� 0-1/ / [ \! \ (\ § ! }\
® / # a. / i # j $ < m / « § g § /
\ o / / / \ j / % / $ \ § \ ) j >
E o 0 o E 4 2 E K = o u o o < w )
I
2 m 7
CD & K
2 } CL
U) , -
M ƒCD \
\) \ ae -j \
a,w 7
\t\ 9 E
g \ 0 (\ ( {
% 2 m Mz / \/
\ \ 9 c/ It
_ \ s mm »)( 0 \
G \ my \\{ / § &
\ ,
j § §± ` � � o (
,< / \( ) M
§\ � �)
wo /( §
m �>
° ° \%
)§ 2 & R2%\
)) [
= 2 > m 2
\ � ^ § \ @)
e \ k (q { 4
o � < § Q
2 co
* jg ID
% / m
} } m \
9 mm ;_ �
m0 /
m4 \ ! a
m m \ \ (
mmoo
§ ///) rn
rn
C. „ e/ 7
{{> .
-Aw Do ) j CD
® CD 0> < k g
{ S ° m m
# § v
CD
m
n
§
k cz /
%
- 2
m
�
/j4
0ww �
CD § m §` v
U 6
Q to d
F >- o 0 0
r r r
Z O
O
V
N
U o 0
� o 0
T
� U
J o
F-LU
o
W
w
W CL o 0
0 0 0
> » e>
u O
p U o0
0
O A
w Z N
(D w N V o 0
Q LL1
2 p L) yr ea o
U o
O Q n
Z u�
0 voi voi. o
p eh M �
N O O N ul
O V
m r
> M M a M
� fA fA fA
Z p ti p
n co
Ch fh N
w co N O o 0
C] co
eo co z Y w U N
O
r- � o U
F O
w U Z a o
U, Z m co a N o
Z p F a tj o
(� c d U o »
E >
w o ~ p
Oa Q o 0
E 0- Z Z U o 0
_� a) cr _
@ O O
Q U r L U q
w ro d d w N o
LL O (n () O O O O N O
O
N N r N N
Q CO Q LO O m N V!
NCD
J CO a�i w fNA w
w O N �` W p
a o w Ld
m p U o 0 0
w C N a o 0
W '> O ) .W U w » o N
Q Q- p Ql w m
L N
N N V N Q a
N M1 p Y Y m o m o iv ti
M
o M LN
o co U Cl) Z G X1 p U w p
H
z
K Z
W
O
O t 4 a
w z E-
L) y z
*k # w z O cn o
F _ t U
t11 U U Q c~>
UZ h U z o w U
O
n
w UU o
W w U w71
O
Q Q F Q � ¢ p w N
W O O Qp � aw
-) w � T
n O O O z
OO ~ O Q r- 0 w w
Q
a w w u w J a o
W tY w ¢ E- p
Tk c r z w -�
pO Z d } s E- W a 0O Cz-7 w o , D . F y
O LL Q w Z X w o � w 0 >
Cl- U U U ti U) L o w 0 0 0 2 it
�u X o
m m
< D o v
CD O m m
Z ( n
to c m
O T �-a m
70
1
O n CJ 000 -C o
3 w w w m w d
m 3
+n (D (MD (OD (D (D (D #
z m m m m m m
ry N `•� V O V n. W U # a
v m m ;Gz z1� :70 u;ux1 �u ;] n v
o D m m0 h h 00
n n n ��', wwwwwwww
m � 0 w wwwcowww
O O O O
m O j 0 0 0 O A A A A 1 W N
W > w . .
to 9 a (� n n_I) g ? � oo -� 00000 p
N N 5 i ro@ (° ro ro ro ro ro 0 0 0 0 0 0 0 ? =
5.
= fl" N m V)T 53???S?? c0 N (n -� (0 --` m
m m z m Z m ro ro m ro m ro ro
m o 0
rtpl � p .�cc c c c'a•o
p Z lfl y m ai m et ro m` w p
z Z c N
_� f D
Ti G (p' N 4i 0(p'ro'N N tU A N m N N Z
;0 O N fn 0 (A N (n N 0 w w w G) A W W -1 0
C
_
mz N
c c c c c
=i= m m m m mrrrrrrrz
-G(A 3 J „�. •�-. �. -�. D m -n MM iIM Zt
�5n aaaaaaaa
r 0 d m m E
-I z m T D p w y rn rn a co y y
,{ 0 -,, m
m m � O
m O C i
�� m m
n �m r
to <o
to m \N ID
-�v
` xm m
o m m z
= m Oy
_ 3 Q m m
pv
c oO
B am CO
W IU 1 m
m
O o o-o-o O to
o w et< N a u)) N
DOx W N N N
O
T
-i
m
I z w 4 D m
m n A
G 4l
a m m
Y� m
v � c
v) Err toZ Z A W N w m m w Ut W N W
j O oP �w�Im0 � �
rL 00000000 �l
0 0 0 o o o O
o m
d'u3 to;?,�,•, fn Fn
� O O O o p O 0 o r
N O O U �_, o O
0
(D
N
FORT WORTH
TRANSPORTATION AND PUBLIC WORKS
PIPE REPORT FOR:
PROJECT NAME: Trails Of Elizabeth Creek Phase 8
PROJECT NUMBER: 102608
DOE NUMBER:
WATER
PIPE LAID SIZE TYPE OF PIPE LF
WATER 8" PVC C900 5552
Water Service 1" Copper 160 EA
FUZE HYDRANTS: 3 VALVES(16" OR LARGER) N/A
PIPE ABANDONED SIZE TYPE OF PIPE LF
DENSITIES: YES
NEW SERVICES:
SEWER
PIPE LAID SIZE TYPE OF PIPE LF
Sewer 8" HDPE 3896
Sewer Service 4" HDPE 129 EA
PIPE ABANDONED SIZE TYPE OF PIPE LF
DENSITIES: YES
NEW SERVICES:
TRANSPORTATION AND PUBLIC WORKS
s` The City of Fort Worth• 1000 Throckmorton Street•Fort Worth,TX 76012-6311
(817)392-7941 •Fax:(817)392-7845
FORT WORTH 00
TRANSPORTATION AND PUBLIC WORKS
August 30, 2021
Burnsco Construction, Inc.
6331 Southwest Blvd.
Benbrook,Texas 76132
RE: Acceptance Letter
Project Name: Trails of Elizabeth Creek Phase 8
Project Type: Water, Sewer, Drainage
City Project No.: 102608
To Whom It May Concern:
On August 17, 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 August 30, 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 August 30, 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-
392-7872.
Sincerely,
Khal Taafar-1 P.E.
Khal Jaafari P.E.(Sep 10,202119:38 CDT)
Khal Jaafari, Project Manager
Cc: Jesse Davis, Inspector
Mike Glover, Inspection Supervisor
Randy Horton, Senior Inspector
Victor Tornero, Program Manager
UA Consultant, Consultant
Burnsco Construction, Inc., Contractor
Foresatar USA Teal Estate Group, Inc., Developer
File
E-Mail: TPW_Acceptance@fortworthtexas.gov
OFFICIAL RECORD
CITY SECRETARY
FT.WORTH, TX
AFFMAV[T
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, Vice
President, 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;
Trails of Elizabeth Creek Ph. S -Water, Sanitary Sewer and Storm Drain
BY
Ab Gran es, ice President
Subscribed and sworn before me on this date 10th of September, 2021.
- 7 77 CLSiLIA LANALES
�, ,`: Notary iQ ill31652996
Notary Public .,y,` My COmrniswon Expires
Tarrant County, Texas _ : .July 71,207
A
CONSENT OF OWNER ❑
SURETY COMPANY ARCHITECT ❑
TO FINAL PAYMENT CONTRACTOR El
SURETY ❑
Conforms with the American Institute of OTHER
Architects,AIA Document G707
Bond No 022228788
PROJECT:
(name, address)Trails of Elizabeth Creek Phase 8
TO (Owner) Fort Worth. TX
FORESTAR(USA)REAL ESTATE GROUP,INC.AND ARCHITECT'S PROJECT NO:
CITY OF FORT WORTH
CONTRACT FOR:
14755 Preston Road,Suite 130 Trails of Flizabeth Creek Phase 8-Water,Sanitary Sewer and
TX 75254 Drainage Improvements
Dallas
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 Surety Companyl
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)
FORESTAR(USA)REAL ESTATE GROUP, INC.AND CITY OF FORT WORTH
14755 Preston Road, Suite 130
Dallas TX 75254 OWNER,
as set forth in the said Surety Company's bond.
IN WITNESS,WHEREOF,
the Surety Company has hereunto set its hand this 20th day of August, 2021
LIBERTY MUTUAL INSURANCE COMPANY
Surety Company
Attest: ,
(Seal): �Lf�-- 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 limits the acts of those named herein,and they have no authority to
10� . 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 duty 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;Tonne Petranek
all of the city of Dallas stale of TX each individually if there be more than one named,its true and lawful attomay-in-fact to matte,
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 awn 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
SUR �ZY INS �rtsu Liberty Mutual Insurance Company
` 1N
�Q yy JP &A R The Ohio Casualty Insurance Company
=L°¢ 4 qlFQ m e Zc°RP O��TFp 20 a Pr°�POR4ro1Pm West American Insurance Company
(6 r 1912 y o 0 1919 � Lau n
d) rd-V �{` 3 y ern o 4 0 /i/
.�� 4 41
CHUS as O HAmp aaS� YS NOIA91�' da Lf /I IV Q
i7 * }N sH1 * 1� 9R tiN By:1713
U
m State of PENNSYLVANIA David M.Carey,Assistant Secretary a
�5
w County of MONTGOMERY 88
U 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 co
0
eu 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-'E
'D 7 therein contained by signing on behalf of the corporations by himself as a duly authorized officer, u
m Co }IY
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
CAP o m 0-O
Commonwealth of Pennsylvania-Not"sea3
9 do ? Teresa Pastella,Notary Public Ita."
�Montgomery County �C _ My commissionexpires March28,2025 gy. E N
Commission number 1126044 ---
(D Member,Pennsylvania Assmiafion of Notaries Teresa Pastella,Notary Public Q `p
CD
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 3
.� Insurance Company,and West American Insurance Company which resolutions are now in full farce and effect reading as follows: o N
ARTICLE IV—OFFICERS:Section 12.Power of Attorney. °mo
1- Any officer or other official of the Corporation authorized for that purpose in writing by the Chairman or the President,and subject to such limitation as the Chairman or the a o
-6 a President may prescribe,shall appoint such attorneys-in-fact,as ma be necessary to act in behalf of the Corporation to make,execute,seal,acknowledge and deliver as surety cco
c� Y P PPyto
M C 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-
o -- 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 IL)
0 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 attomey-in-fact under the Q
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. o
Q
ARTICLE XIII—Execution of Contracts:Section 5.Surety Bands 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 faesimlle 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,Llberty Mutual Irisurance 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.
IN TESTIMONY WHEREOF,I have hereunto set my hand and affixed the seals of said Companies this. 20th day of August 2021
INZlik,� 'SY INS. a I ljlu
j=G°P.POr7gTo+jm �J=`°srogl�'�qy �yP`°aPORRT4'f,C
1912 0 0 2 1919 o 1991 0
�39SSACHVSE�aDY� s0 yRM95��a �NDlANI" a� By.
k�a Renee C.Llewellyn,Assistant Secretary
LMS-12873 LMIC ODC WAIC Multi Co a2121
ibert
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 Ilamar at 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 eI 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 at
1-800-252-3439
You may write the Texas Department of Insurance Puede escribir al Departamento de Seguros
Consumer Protection (I I I-IA) de Texas Consumer Protection (I I I-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: htt ://www.tdi.texaL. ov Web: htt ://www.tdi.texas. ov
E-mail: ConsumerProtectionna tdi texas. ov E-mail: ConsunierProtection@tdi.texas.gov
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 1a 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:
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 eonvierte en parte o condicion del
document. documento adjunto.
NP7068090I
LMS-15292 10115