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Contract 51536-R3FP1
FORT WORTH, -"Wqw,- TRANSPORTATION AND PUBLIC WORKS NOTICE OF PROJECT COMPLETION City Secretary No:_51536-R3 FP1 Date Received: May 13, 2022 City Project Ns: UC01-2018 Regarding contract 51536-R3 for UTILITY CUT REPAIR CONTRACT 2018 as required by the WATER DEPARTMENT as approved by City Council on 11/16/2018 through M&C C-28921 the director of the WATER DEPARTMENT upon the recommendation of the Assistant Director of the Transportation&Public Works Department has accepted the project as complete. Original Contract Prices: $1,843,977.90 Amount of Approved Change Orders: $ No. Revised Contract Amount: $ Total Cost Work Completed: $ 799,682.20 Less Deductions: Liquidated Damages: 0 Days Q$210.001 Day Pavement Deficiencies: Total Deduction Amount: $0.00 Total Cost Work Completed: $ 799,682.20 Less Previous Payments: $ 799,682.20 Final Payment Due $ 0.00 LAWO"y May 10, 2022 Lauren Prieur(May 10,202210:02 CDT) Recommended for Acceptance Asst. Date Director, TPW-Captial Delivery DEPARTMENT Chrisfovhev lfardev May 13, 2022 Christopher Harder(May 13,2022 11:53 CDT) Accepted Date Director, WATER DEPARTMENT Client Department 11-1�14r�ze May 13,2022 Asst. City Manager Date OFFICIAL RECORD Comments: CITY SECRETARY FT.WORTH, TX FORTWQRTH CITY OF FORT WORTH FINAL,PAYMENT REQUEST Contract Name UTILITY CUT REPAIR CONTRACT 2018 Contract Limits 3RD AND FINAL RENEWAL Project Type PAVING City Project Numbers UC01-2018 DOE Number 2018 Estimate Number 15 Payment Number 15 For Period Ending 4/26/2022 CD City Secretary Contract Number 51536-R3 Contract Time 369D Contract Date Days Charged to Date 242 Project Manager NA Contract is 43.000 Complete Contractor WESTHILL CONSTRUCTION,INC. P.O.BOX 2016 CLEBURNE, TX 76031 Inspectors GLOVER / WATSON Wednesday,May 4,2022 Page I of 7 City Project Numbers UC01-2018 DOE Number 2018 Contract Name UTILITY CUT REPAIR CONTRACT 2018. Estimate Number is Contract Limits 3RD AND FINAL RENEWAL Payment Number 15 Project Type PAVING For-Period Ending 4/26/2022 Project Funding UNIT I:CUTS LESS TI IAN 200 SQUARE FT Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total I 3-inch Asphalt Pavement,Type D 4000 SY $36.00 $144,000.00 162.01 $5,832.36 2 3-inch Asphalt Base,Type B 1200 SY $10.00 $12,000.00 3 9-inch Concrete Pavement 700 SY $90.00 $63,000.00 203.91 $18,351.90 4 11-inch Concrete Pavement 300 SY $99.00 $29,700.00 5 Min.8-inch Concrete Base Material 3200 SY $45.00 $144,000.00 125.4 $5,643.00 6 Min.5-inch Reinforced Concrete Base 800 SY $63.00 $50,400.00 22.22 $1,399.86 7 Brick Pavement Repair 150 SY $36.00 $5,400.00 Sub-Total of Previous Unit $448,500.00 $31,227.12 UNIT II:CUTS GREATER THAN 200 BUT LESS Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Qumlity Total Quanity Total 1 3-inch Asphalt Pavement,Type D 4000 SY $36.00 $144,000.00 976.87 $35,167.32 2 3-inch Asphalt Base,Type B 1200 SY $20.00 $24,000.00 3 9-inch Concrete Pavement 700 SY $90.00 $63,000.00 459.17 $41,325.30 4 1 I-inch Concrete Pavement 300 SY $99.00 $29,700.00 77.17 $7,639.83 5 Min.8-inch Concrete Base Material 3200 SY $90.00 $288,000.00 688.37 $61,953.30 6 Min.5-inch Reinforced Concrete Base 800 SY $63.00 $50,400.00 7 Brick Pavement Repair 150 SY $54.00 $8,100.00 82.67 $4,464.18 Sub-Total of Previous Unit $607,200.00 $150,549.93 UNIT III:CUTS GREATER THAN 1000 SQ FT Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total 1 3-inch Asphalt Pavement,Type D - 3000 SY $36.00 $108,000.00 5071.98 $182,591,28 2 3-inch Asphalt Base,Type B 900 SY $12.00 $10,800.00 3 9-inch Concrete Pavement 700 SY $90.00 $63,000.00 4 11-inch Concrete Pavement 300 SY $99.00 $29,700.00 5 Min.8-inch Concrete Base Material 2400 SY $72.00 $172,900.00 1238.28 $89,156,16 6 Min.5-inch Reinforced Concrete Base 600 SY $72.00 $43,200.00 7 Brick Pavement Repair 150 SY $45.00 $6,750.00 Wednesday,May 4,2022 Page 2 of 7 City Project Numbers UC01-2018 DOG Number 2018 Contract Name UTILITY CUT REPAIR CONTRACT 2018 Estimate Number 15 Contract Limits 31ZD AND FINAL RENEWAL Payment Number 15 Project Type PAVING For Period Ending 4/26/2022 Project Funding 8 4"REINFORCED CONCRETE SIDEWALK 450 SF $8.00 $3,600.00 117.5 $940.00 Sub-Total of Previous Unit $437,850.00 $272,687.44 UNIT IV:ALL CUPS ASPHALT W/O BASE RE Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total 1 3-inch Asphalt Pavement,Type D 2000 SY $27.00 $54,000.00 2 3-inch Asphalt Base,Type B 600 SY $10.00 $6,000.00 3 4-inch Asphalt Base,Type B 200 SY $27.00 $5,400.00 4 5-inch Asphalt Base,Type B 200 SY $27.00 $5,400.00 5 6-inch Asphalt Base,Type B 200 SY $36.00 $7,200.00 Sub-Total of Previous Unit $78,000.00 UNIT V:ADDITIONAL ITEMS REQ OTHER THAN Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total I 7-inch Concrete Curb and Gutter 400 LF $35.00 $14,000.00 434.5 $15,207.50 2 7-inch Concrete Curb and Gutter Attached to 400 LF $20.00 $8,000.00 Concrete Pavement 3 6-inch Reinforced Concrete Driveway 100 SF $10.00 $1,000.00 4622 $46,220.00 4 4-inch Reinforced Concrete Driveway and 150 SF $50.00 $7,500.00 404.5 $20,225.00 Wheelchair Ramp 5 Topsoil 50 CY $30.00 $1,500.00 10.52 $315.60 6 Manhole Adjustment,Minor 1 EA $500.00 $500.00 7 Miscellaneous Structure Adjustment,Valve Vault 1 EA $500.00 $500.00 Adjustment 8 Imported Embedment/Backfill,Crashed Rock 50 CY $50.00 $2,500.00 10 $500.00 9 2-inch Asphalt Pavement,Type D,Parking Lot Repair 50 SY $63.00 $3,150.00 10 6-inch Lime Treatment 50 SY $19.00 $950.00 11 2-inch Asphalt Pavement,Type D,Driveway Repair 50 SY $72.00 $3,600.00 12 4-inch Flexible Base,Type A,Grade 1-Crushed 75 SY $27.00 $2,025.00 Limestone 13 6-inch Flexible Base,Type A,Grade 1-Crushed 75 SY $36.00 $2,700.00 Limestone 14 Class'A'Concrete(3,00011) l0 CY $200.00 $2,000.00 15 Repair Storm DrainSlructures 5 CY $300.00 $1,500.00 Wednesday,May 4,2022 Page 3 of 7 City Project Numbers UC01-2018 DOE Number 2018 Contract Name UTILITY CUT REPAIR CONTRACT 2018 Estimate Number 15 Contract Limits 3RD AND FINAL RENEWAL Payment Number 15 Project Type PAVING For Period Ending 4/26/2022 Project Funding 16 Concrete Manhole Collar I EA $300.00 $300.00 17 Joint Sealing-Silicone 200 LF $2.00 $400.00 18 Relocate Water Meter and Box I EA $150.00 $150.00 2 $300.00 19 Water Meter Adjustment 1 EA $100.00 $100.00 20 Saw-cut Concrete Pavement 200 LF $3.00 $600.00 21 6-inch Concrete Pavement,High Early Strength 150 SY $108.00 $16,200.00 Concrete(HES) 22 Utility Adjustment I LS $1,000.00 $1,000.00 23 9-inch Concrete Valley Gutter,Residential 70 SY $99.00 $6,930.00 13.33 $1,319.67 24 Raised Traffic Markers,All Types 20 EA $10.00 $200.00 35 $350.00 25 Pavement Marking,All Types 100 LF $30.00 $3,000.00 1805 $54,150.00 26 Concrete Riprap 30 SY $54.00 $1,620.00 27 Medium Stone Riprap,Dry 60 SY $54.00 $3,240.00 28 Large Stone Riprap,Dry 60 SY $63.00 $3,780.00 29 Concrete Retaining Wall 20 CY $300.00 $6,000.00 30 Street Use Permit 100 EA $100.00 $10,000.00 31 Traffic Control Plan Design and Install as Required 15 EA $100.00 $1,500.00 32 HAUL OFF OF ASPHALT 200 EA $100.00 $20,000.00 100 $10,000.00 62 STAMP AND STAIN CONCRETE 549 SF $14.00 $7,686.00 33 IT CONCRETE INLET I EA S6,750.00 $6,750.00 35 4"REINFORCED CONCRETE 20 SF $8.00 $160.00 670.5 $5,364.00 34 CRUSHED ROCK 8 CY $50.00 $400.00 35 5"ASPHALT PAVEMENT TYPE D 1 I I 1 SY $60.00 $66,660.00 36 HAUL OFF 38.07 CY S100.00 $3,807.00 37 3"MILL 4145 SY $5.00 $20,725.00 5185 $25,925.00 65 IT CONCRETE STORM DRAINAGE INLET I EA $6,750.00 $6,750.00 62 STAMP&STAIN CONCRETE 140 SF $14.00 $1,960.00 66 4"REINFORCED CONCRETE SIDEWALK 300 SF $8.00 $2,400.00 89 $712.00 67 3"MILLING 4438.26 SF $5.00 $22,191.30 31531.46 $157,657.30 68 STREET SWEEPER 4 HR $100.00 $400.00 5 $500.00 66 4"ASPHALT PAVEMENT TYPE D 20.22 SY $48.00 $970.56 63 5"ASPHALT TYPE D 60 SY $41.78 $2,506.80 64 4"REINFORCED CONCRETE SIDEWALK 120 SF $8.00 $960.00 414.5 $3,316.00 69 GRASS 12 SY $12.00 $144.00 136.95 $1,643.40 70 SPRINKLER REPAIR I LS $375.00 $375.00 1 $375.00 Wednesday,May 4,2022 Page 4 of 7 City Project Numbers UC01-2018 DOE Number 2018 Contract Name UTILITY CUT REPAIR CONTRACT 2018 Estimate Number 15 Contract Limits 3RD AND FINAL RENEWAL Payment Number 15 Project Type PAVING For Period Ending 4/26/2022 Project Funding 71 SPRINKLER REPAIR 1 LS $250.00 $250.00 1 $250.00 72 SPRINKLER REPAIR I LS $487.00 $487.00 1 $487.00 73 G"TYPE A GRADE I LIMESTONE 8.34 CY $36.00 $300.24 8.34 $300.24 74 WATER METER ADJUSTMENT 1 EA $100.00 $100.00 1 $100.00 Sub-Total of Previous Unit $272,427.90 $345,217.71 -------------------------------------- Wednesday,May 4,2022 Page 5 of 7 City Project Numbers UC01-2018 DOE Number 2018 Contract Name U7'ILI'1'Y CUT REPAIR CONTRACT 2018 Estimate Number 15 Contract Limits 3RD AND FINAL RENEWAL Payment Number 15 Project Type PAVING For Period Ending 4/2 612 0 2 2 PrajectTunding Contract Information Summary Original Contract Amount $1,842,321.66 Change Orders Total Contract Price $1,843,977.90 .4h9ael.�Ave D� May 5,2022 Total Cost of Work Completed $799,682.20 AnQ aReynolds(Ma 5,20221458CDTj Date Contractor Less %Retained $0.00 �, Net Earned $799,682.20 �..�.s. May 5,2022 Mi<6ae IO.Gl:!er(May5,202215:20CDT) Date Earned This Period $0.00 Inspection Supervisor C. 12 Retainage This Period $0.00 �G May 10,2022 u,d,m,,d(Mav1O.202209:09CDT) iliate Less Liquidated Damages Project Manager Days @ /Day $0.00 ChLstoaher Nclyder May 13,2022 Christopher arder(May 13,2022 11:53 CDT) Date LessPavement Deficiency $0.00 Director/WA7'ER DEPARTMENT Less Penalty $0.00 Less Previous Payment $799,682.20 i Plus Material on Hand Less 15% $0.00 4 Balance Due This Payment $0.00 i i f t f Wednesday,May 4,2022 Page 6 of 7 City Project Numbers UCOI-2018 DOE Number 2018 Contract Name UTILITY CUT REPAIR CONTRACT 2018 Estimate Number 15 Contract Limits 3RD AND FINAL RENEWAL Payment Number 15 Project Type PAVING For Period Ending 4/26/2022 Project Funding Project Manager NA City Secretary Contract Number 51536-R3 Inspectors GLOVER / WATSON Contract Date Contractor WESTHILL CONSTRUCTION,INC. Contract Time 365 CD P.O.BOX 2016 Days Charged to Date 242 CD CLEBURNE, TX 76031 Cant►•act is .000000 Complete CITY OF FORT WORTH SUMMARY OF CHARGES Line Fund Account Center Amount Gross Retainage Net Funded Total Cost of Worlt Completed $799,682.20 Less %Retained $0.00 Net Earned $799,682.20 Earned This Period $0.00 Retainage This Period $0.00 Less Liquidated Damages 0 Days n $0.00 /Day $0.00 LessPavement Deficiency $0.00 Less Penalty $0.00 Less Previous Payment $799,682.20 Plus Material on Hand Less 15% $0.00 Balance Due This Payment $0.00 Wednesday,May 4,2022 Page 7 of 7 FORT WORTH rev 03/05/07 T TRANSPORTATION&PUBLIC WORKS FINAL STATEMENT OF CONTRACT TIME FINAL STATEMENT NO.:15 NAME OF PROJECT: Utility Cut Repair Contract 2018 3rd Renewal PROJECT NO.: UCO1-2018 CONTRACTOR: West Hill Construction DOE NO., NA PERIOD FROM:03/30/22 TO: 04/26/22 FINAL INSPECTION DATE: 26-Apr WORK ORDER EFFECTIVE:7/1/2021 CONTRACT TIME: 365 Q WDQ 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 27 27 PERIOD PREVIOUS 0 0 0 0 215 215 PERIOD TOTALS 0 0 0 0 242 242 TO DATE *REMARKS: i".,y 5,1�121J May 5,2022 Donald Watson 5/2/22 CONTRACTOR DATE INSPECTOR DATE ENGINEERING DEPARTi\IENT � / The City of Fort Worth• 1000 Throclunorton Street•Fort Worth,TX 76012-6311 (817)392-7941 ,Fax:(817)392-7845 FORT WORTH. TRANSPORTATION AND PUBLIC WORKS May 2, 2022 Westhill Construction,inc PO. BOX 2016 Cleburne,TX 76033 RE: Acceptance Letter Project Name: Utility Cut Repair Contract 2018 3`d Renewal Project Type: Paving City Project No.: UCO!-2018 To Whom It May Concern: On April 26, 2022 a final inspection was made on the subject project. There were no punch list items identified at that time. The final inspection indicates that the work meets the City of Fort Worth specifications and is therefore accepted by the City. The warranty period will start on May 26, 2022, which is the date of the final inspection 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- 392-2629. Sincerely, John Underwood, Project Manager Cc: Donald Watson, Inspector Mike Glover, Inspection Supervisor Randy Horton,Senior Inspector John Kasavich, Program Manager NA, Consultant Westhill Construction, Contractor NA, Developer File E-Mail: TPW_Acceptance@fortworthtexas.gov Rev.08/20/19 AFFIDAVIT STATE OF TEXAS COUNTY OF JOHNSON Before me,the undersigned authority, a notary public in the state and county aforesaid, on this day personally appeared Angela Reynolds, President of Westhill Construction, Inc., known to me to be a credible person, who being by me duly sworn, upon her 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 Utility Cut Repair Contract 2018, 3rd renewal. By Q!����� Angela Reynolds of Westhill onstruction, Inc. Subscribed and sworn before me on this date 14TH day of April, 2022 -K 4�u Notary Publi Johnson County, Texas MARILYN K.NEWBY Public '* STATE nme OF TEXAS MNCoroml XP A Y19,2024 0 =10-- Document G707Th1 — 1994 Consent Of Surety to Final Payment Bond#4423875-R3 PROJECT:(Name and address) ARCHITECT'S PROJECT NUMBER: OWNER: Third&Final Renewal of Utility Cut Repair .Contract 2018 CONTRACT FOR: General Construction ARCHITECT: TO OWNER:(Nome and address) CONTRACT DATED: CONTRACTOR: City of Fort Worth 1000 Throckmorton St SURETY: Fort Worth,TX 76102 OTHER: In accordance with the provisions of the Contract between the Owner and the Contractor as indicated above,the (Insert name and oddness of Surely) Markel Insurance Company 4521 Highwood Parkway Glen Allen,VA 23060 ,SURETY, on bond of (Insert name and address of Contractor) Westhili Construction, Inc. PO Box 2016 Cleburne,TX 76033 ,CONTRACTOR, hereby approves of the final payment to the Contractor,and agrees that final payment to the Contractor shall not relieve the Surety of any of its obligations to (Insent name and address of Owne)) City of Fort Worth 1000 Throckmorton St Fort Worth,TX 76102 OWNER, as set forth in said Surety's bond. IN WITNESS WHEREOF,the Surety has hereunto set its hand on this date: April 12,2022 (Insent in uniting the month followed by the numeric date and year.) Markel Insurance Company ($w•ety) 't�K A ( ignathn•e of authorized representative) Attest: Teresa Godsey,Attorney-in-Fact (Seal): (Primed name and title) AIA Document G707VI-1994.Copyright©1902 and 1994 by The American Institute of Architects. All rights reserved. WARNING:This AIA®Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIAe Document,or any portion of It, 1 may result In severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law. This document was produced by AIA software at 15:04:04 on 02/09/2009 under Order No.1000374646_1 which expires on 1011312009,and Is not for resale. User Notes: (1452131059) POA If: 4423875-R3 Markel Insurance Company LIMITED POWER OF ATTORNEY Know All Men by These Presents,That MARKEL INSURANCE COMPANY(the"Company"),a corporation duly organized and existing under the laws of the State of Illinois,and having its principal administrative office in Glen Allen,Virginia,does by these presents make,constitute and appoint Teresa Godsey its true and lawful Attorney-in-fact,with full power and authority hereby conferred in Its name,place and stead,to execute,acknowledge and deliverany and all bonds,recognizances,undertakings of other instruments or contracts of suretyship to include waivers to the conditions of contracts and consents of surely for, providing the bond penalty does not exceed Principal: Westhill Construction, Inc. obligee: City of Fort Worth Amounts:$$799,682.20 and to bind the Company thereby as fully and to the sarne extent as if such bond were signed by the President,sealed with the corporate seal of the Company and duly attested by Its Secretary,hereby ratifying and confirming all that the said Attorney-in-Fact may do in the premises.Said appointment is made under and by authority of the following resolution of the Board of Directors of Markel Insurance Company: RESOLVED,that the President,any Senior Vice President,Vice President,Assistant Vice President,Secretary,Assistant Secretary or Assistant Treasurer shall be and is hereby vested with full power and authority to appoint any one or more suitable persons as Attorneys)-in-Fact to represent and act for on behalf of the Company,subject to the following provisions: Attorney-in-Fact may be given full power and authority for and in the name of and on behalf of the Company,to execute,acknowledge and deliver,any and all bonds,recognizances,contracts,agreements or indemnity and other conditional or obligatory undertakings and any and all notices and documents canceling or terminating the Company's liability thereunder,and anysuch Instruments so executed by anysuch Attorney- in-Fact shall be binding upon the Company as if signed by the President and sealed and effected by the Secretary. FURTHER RESOLVED,that the signature of any authorized officer and seal of the Company heretofore orhereafter affixed to any powerof attorney or any certificate relating thereto by facsimile,and any power of attorney or certificate bearing facsimile signature or facsimile seal shall be valid and binding upon the Company with respect to any bond or undertaking to which It is attached. In Witness Whereof,MARKEL INSURANCE COMPANY has caused these presents to be signed by its Senior Vice President,and its corporate seal to be hereto affixed this 9th day of September,2019. `ss„i,,,," ,`•`'otikak�X MARKEL INS �Af CE C PANY ' SEAL 'O`= Commonwealth of Virginia '� B V Henrico County '%., �s�� y Rob Russo,Senior Vice President On this 9th day of September,2019 before me personally came Robin Russo t 1Q(prMown,who being by me duly sworn,did depose and say that he resides in Henrico County,Virginia,the he is Senior Vice President of MARKEL IfyS h�CU�9WAIIY,3he company described in and which executed the above Instrument;that lie knows the seal of said Company;that the seal affixed to said in�Nlii56uctraa fele RS�aI;that it was so affixed by order of the Board of Directors of said Company;and that he signed his name thereto by like order. ZQ SPRY pie' 2j _ COMMISSION =BY: 0', NUNIF3ER Donna Donavant,Notary Public 7083968 My commission expires 1/31/2023 I,Richard R.Grinnan,Vice President and Secretary of MARKEL INSUR QSlxPwdo h�'4by certlfy that the above and foregoing is true and correct copy of a Power of Attorney,executed by said Company,which is still in full force andbffoati m-10 urthermore,the resolutions of the Board of Directors,set out in the Power of Attorney are in full force and effect. Given under my hand and the seal of said Company at Glen Allen,Virginia this 12th day of Aril 20 22, By: Richard R.Grinnan, Vice President and Secretary Any Instrument Issued In excess of the penalty stated above is totallyvold and without any validity, Far verification of the authority of this Power you may call(713)812-0800 on any business day between 8:30 AM and 5:00 PM CST. Markel Insurance Company THIS BOND RIDER CONTAINS IMPORTANT COVERAGE INFORMATION Statutory Complaint Notice/Filing of Claims To obtain information or make a complaint: You may call the Surety's toll free telephone number for information or to make a complaint or file a claim at: 1-866-732-0099. You may also write to the Surety at: Markel Insurance Company 9737 Great Hills Trail, Suite 320 Austin,Tx 78759 You may contact the Texas Department of Insurance to obtain information on companies, coverage, rights or complaints at 1-800-252-3439.You may write the Texas Department of Insurance at: PO Box 149104 Austin, TX 78714-9104 Fax#: 512-490-1007 Web: http://Www.tdi.state.tx.us Email: ConsumerProtection@tdi.texas.gov PREMIUM OR CLAIMS DISPUTES: Should you have a dispute concerning your premium or about a claim, you should contact the Surety first. If the dispute is not resolved, you may contact the Texas Department of Insurance. ---------------------------------------------------------------------------------------------- Signature: C�l�'/ItDdGIG�'l`fGl!Ww- Christopher H rder(May 10,2022 10:01 CDT) Email: christopher.harder@fortworthtexas.gov Texas Rider 06042015 1