HomeMy WebLinkAboutContract 55267-FP1 FORT WORTH®
TRANSPORTATION AND PUBLIC WORKS
NOTICE OF PROJECT COMPLETION
City Secretary No: 55267-FP1
Date Received:Aug 16,2022
City Project NO:101452
Regarding contract 55267 for as required by the TRANSPORTATION AND PUBLIC WORKS
DEPARTMENT as approved by City Council on 04/12/2022 through M&C 22-0294 the director of the
TRANSPORTATION AND PUBLIC WORKS DEPARTMENT upon the recommendation of the Assistant
Director of the Transportation&Public Works Department has accepted the project as complete.
Original Contract Prices: $4,478,841.30
Amount of Approved Change Orders: $ 0.00 N- V
Revised Contract Amount: $4,478,841.30
Total Cost Work Completed: $3,923,017.12
Less Deductions:
Liquidated Damages: 0 Days Qa $650.00/Day
Pavement Deficiencies:
Total Deduction Amount: $0.00
Total Cost Work Completed: $3,923,017.12
Less Previous Payments: $ 726,866.26
Final Payment Due $ 196,150.86
v� Aug 12, 2022
Recommended for Acceptance Date
Interim Asst. Director, TPW - Capital
Delivery
Aug 12, 2022
Accepted Date
Interim Director,TRANSPORTATION AND PUBLIC WORKS
DEPARTMENT
Cli t artment Aug 12, 2022
William Johnson(A 12,20221312 CDT)
Date OFFICIAL RECORD
Asst. City Manager CITY SECRETARY
Comments: FT.WORTH, TX
C 620 Signaluro Pogo
Conhrncto0s A)Iliention for Payment Invoice No. 17-FINAL
1'o(O%meU City of Fort Wortil Invoking Period(I§on-To): final"Date:
7)121-'/25/22 7/25/2022
I'•O• FW020-0000005069 Plan,(Coo—ter); Itemino(IfNol Aulonullo tkpo4t);
Number: McClendon Contutsctiol Cotn mt Ina
Project: 101452 Ce'ar" e.CFW Vander No.:
0000007d0)
city SmarmyCunt.al 55267 ConbK120I8 CIP Your 3—Contract 5
Number: Nance:
Application Far Payment
Chan cUrder Sumnu
A mad CM aOrders 1.ORIGINAL CONTRAcrPRICE............................ S S(.a78,8T1.d0
Number Addition Ikloliom 2,Neldunge by Change Orden..................I................ S
1 3.Current Coal aI Price(Line I A U........................................................S S4c178,941.70
2 +.TOTAL COMPLETED AND STORED TO DATE:
5 (P"8"II Eltimare,Censlnraltan Allen oncennd Chong,Orders)....,-S S3.923,017.12
a S.RETAINAM
3 A. 7( 13,923,017.12 Work Completed...,..... S
G b. X ttol Used 3
7 .'tarot Re4lnnFa(M.,So+Line SAI................................S
8 6.AMOUNT F.LIOIBLETO DATE ILine•I•,.bte5e) 5 S5,922,017.12 r�
TOTALS 7.1,E831'ItEVIOUSPAYb1ENTS(I.Ine6r"ntprlorApplkallon)........S S3,716.e66.26 ^�
NUTL'IIANORDY S.AMOUNr DUETIIISAPPLICAr1oN..................................................S S196,150.86 ■/(/ g�� •••
CIIANORORD9113 9.IIAI,ANCE TO FINISII,PLUS RI:TAINAOE
(Ceti.....O on P"gnu Estimates CA+CO,+Us,5 eb—).............. S S555A24.18 / �f✓
Cont"cloes Cerl1rho ton 10,CONrRALT TIAIE. (/
Tho Conbaoar<edfiw with the aubntilml ofthisdoewnenl and atoalaleJ Peynwm liegoed 5ulvrdud Do).Anorded 360
on the City fport Wroth Utv+.ue•ayatrm del to the bail of 0.1,latoaieJge:(1)all I—irur lvotant b. Da),Added by CO
royoenb re"bed(mm Oauer on account of\Vwk done under ilia Cunracl lice been orgdied on a Total Do), 360
"aaunl to discharge ConO"tw9 kgilimdo obligations Incurred in oetutection%Hilt Woik")cud by
riar Applicatbne for @)7nem;(2)Iilto of AI Work,imleriub and equipment incorporoied in raid
Workerolhm%iu lined inoreorered by thtr Application fro Payment%dtl pall in Oaml el lbne of d. Do),Charged 355
pynant freerrd clear ofell liens,security inlemastiM enomnbmnces(eecep sixh at are cm—I by a DA)s Remaining 2
a Dond acceptable to Oover indermtlpiag Mail opaimt arty such[,tons,security interest or
e"%mtNencea);and(3)all Work"%vred by this Appli"Qon for Political is in aeconlsnea uith the
IAquldnred Damage'S650.00 s day
• ate.
I
I
TNs document has been modified from Its ori&nl loam as nn PJCDO document and the user rRd not IJghlight the
modficellons.You via encoumgod to rend Ilia document cmefully and consult Leard Coun"I prior to No execution.
1 1-i81Ak8ti9 YU'?i x v.Ud3timvva ".. ., ,". UUY.it it li�t ,UU'tRl EA P i;
4
aRi t�3 y SY H 8 6 X44 8 �
safi 8 f3 8RRRRa 15�
93:ba&yf ggSSRR g�y¢¢43bbt;.4444gg Rayy4 kag�.��p op'o.4J o+�"Ng§ ��k�9949.8 4S ,� � 9 Fi'§$ .'it Q
I I
I I
II II
I I
i I II
i i II
I
� II
� I I i I i
S:GI«�2�< G6GGoG«2<S"S"S"�S"6GG.2245�4:G'5;6SS,.5;5; "<L"5S"S:,S"5b 55LS:s TG., GoE,I,GGc;t t S S.S,��Y2S'S;S'L"S'S:�S".L"S"SS"'n <`2G S"�"L"TF
Ali
vU.IS9'0 6;;}i R'd•.�w
,I sly,«I 4 �IHI 41k.4�
�•�p' tk 5 g ,,s f���ar iNi3 0µ�p]�y pgj4}9pp �yi 9p pp , sn ty1 s : �&910 0 s$P ds�yks�
8 N$86� g 9.gS g s 88888888888888E 88d68 88$ SBS 8 8: $$ 888 88 8 88 8 8888 S,88888 88,8&1,911i
012%,QQW' HU% {11+6pcp �3 flip s
Ss8.8$$$ S818 SH1$10 8ififl
S B � $: 88 8' .68:886 8 8 .88 s 888898o$
�e U III I IIII � Ili ' 9
un'wgs ilk
9 " 88b.88kgk889988989899� 8a8b88R $B88S ,888. I ,$$88� s 8�p_ 8 $ s8d _$ 8s8 � sss888 8 $SSSSss 8ss86s.8s1
s
r $xu� Kassa'. a �.m ataa $s:a, aNpg" sip. a a� m pis
'�N`Nmsm ... "MnMB ��u oiput B� ng - ���u;;� ag �j� €�>s als��amg
otsao989 : $$888, 8 8008BBB 8'$'$9 88 . �>g89'8. k g99999 9$8 k 901 98�k8�A� BBfi�Bfi�k �
I i I f i l l i II. I I I I I III � I � I
I I I i I I I I I I I II I I i e'
s
l
Env I "3 8
att 1�
19
. .
$8 I
it
8�586Ss8 $I$$,88 $
Its p
fa
8
N 5
� WITII Ill I � I ' � � I i III III IIII I � II � ' � I III
J �kGX�: f3 . s �s' � ,8i:ts I
— yra; p
88s8 .8 6f8 NVNHs§A& 1 4 H r , I.,S f Hn H;kf3 H
8788 4 88 88 "9$8888 888B8889 8 $�1 9 `i n
roa
I I I I II i
I
I
I I
i
I III ' I III i I I �
I I I
i
i i i l I i I
i
Tl�
ILL
I I I I I II I I i I I I II I
II I I I I I I'' I Ili
c`$ s� a ' y. I✓n�+ al I g�&'S; I Id' I is �, � � '�d a I j II I j I i I I i
668$ 8
'$3$B B A688a 14,
BA ! BRBIBa$B
v � e ad alb xd a' dda it
s $ i i I I I I l i ill i i j i
II I I i I' i j I I II I � Ij i I j
I I I ! I I I
F I
� I
.� Aa$a a>asssa$ I a >qR s a a seaea.s IBa$B as I i I ! I i I .� I ' I I i
� ua" ''ad �d � a N�& � 't;�d�r"•a,�5�d�a �s�i4aq I I jl ' j I I I 1 I l f II I I
� " I I Nj it Ijj ! I liil I I
seas aasassR $ I's3a € aea j
$ 86$8$88
y uu Ids Edda a d�
d in x Edda �.
q N ,
8 flF7 R'..p^ I � R n.s .IR9LlN�Fa W.= .- IN j
I I Ij i I I I
>' I��d '9 •- N� F1 B..� ^^ >g"8 ^.8 I I ' I I I ,�
^ N N N
2�57 g2j F�B13>�8��88$8A1F N -NN31 F� N N N Np23 N N N$~ .
SSa�a988888PR88 8R$ A$B Bps BaseaB es
N N
�gp 3._
s"�� asst III '�''{aai CIO re ii.�$8 •.,�'���'�'8 'I�d.;l �N ' I i II I i I
A ! � j• I I I -Ij ,-� I , ! jI I I I I� I I I
I I ' , i � jl I I I I
I I 5356 669 6lh616t;616 ts gS��I� S3 sn
j j I I
I I iI I
II I I liI
gg z ¢¢
HgAg�8g3,5g�g
� a a8xga !' rz3 "t bRoBIA I I '. I !i
W � SU6fiGEf�tlG[i r,n _ nj�n N�I�{�1�T'i',�it•INFi{t�flFi.��'FIRRR��:��7�{AI��'.��'i Sl ' I " � i I I
y
I II J
_ 7
pg 8 F�F1A�Y18 FAR R AFiaR�RAF;A>19VVR8RW0°i
I
!I ( y
3
I
I � e
' 3 I �
I
I I �
li i i j
I I
rr 9. j
I
i
� I
l I i i I I it I g
!
K�
7
I I i IiI i � n
a�. n
I II
: I
i
O O O O O O 0 0 W 01 M O O 0 0 0 0 0 0 C
O O O 11�: (7[7 O
O O O
(D O O O
rnNN gDNN
0 o b o n b
(D o 0
000 0010
000
O O O (1 41 J
0
L)W W W((D
0 0 0
a Ul UI UI VI(M
41 1, ,p .p A .h A A O
0 0 0 0 0 0 0 0 0 .n n 0 0 0 0 0 0 0 0 o c
0 0 0 0 0 0 0 0 0 :3
goon oon 0000 �I ,o
A A A
(Ail m(41 All UI NUI NN N ID D
N N N N N N w
0 0 0(D 0 C. 0@ C'
O O O
O O O O
0 0 0 0 N o o I N O
A I 1'(
.NP m co ID J ID co Go co a , Do Go
co C) n
lD W (D N
(D(D 00 N (U(D(O
D (U (D
cD cD(D cD(D cD rn
(o(D(D (D O (D (p
Oo
0 0
0 0 �
O (D to
O to to
i
N
ram-, O
DD -it
n �I O
ccIn O
Nnrn 3 IQ
(D D
N 4
OAm („ O
(n (n O CL
N O C. UI o rl-
y zy
Nrt( ``^^
N w VJ
n
r.
D v�
3
(D
A � ~ 3 w
Q) w v Y
W� -4 :
a G b
oD000 Q w r
O
(n by O
n o
0
L r g
0
I
(D d �.
i � N �Cy w U P
(D d
N -1
I
O
V
J N
N
UI
Z N
O
,mti. N
N
00000000 (W0101 o0000o0o101C" o000000ID 0,M
A (D (D 0 0 0 0 0 0
ID 0 0 0 0 o n
0 C.0 0 0 0 0(D 0
0(D 0 (D(D(D 0 0 0 N
A A A A A A A A A ry
www www ww
-• oo --goo 00
(T Vl Ul UI Ul UI Dl Dl Dl
A P A .n A � A A A o
CD(D ID 0 0 (D 0 0 0 7
000 000 00o c 9
0 0 0 0 0 0 0 0 0 A
0 0 o n o_ o o n o_ o o n •n p
A A A D:I A A A p:1 A A A p�j •a .9.
Ul Dl Dl Ul (51 Ul Dl Ul Dl (],
N N N IQ N 1 N a IQ N N (p D
0 0 b fD b b b (D (7 O O @ 7 �•
o o o o N o o N o o� O --!I ]
A -I --1 A -1 1
0 0 O(D co co
O O O ID C. O O O cr, a.
(D(D to N to to to ,(� (D (D (D
(D(D(D (D(D (D to (D (D N
(D(D(D (D to (D (D to to Gl
w(D (D to to
O
0 0 0
0 0 0
to p (D
to (D (D
! I
! I
il
91 �; o
�! 1 C
oCD
N (�
N Cn
U1 C
ID
3
a� v
o
� •- N (D
In, O
0
Y o
r o
V1
0
b
2
�• 7_
(D _d N
it o
J N
N
U1
Z N
C
ice-( N
N
I
I
o000000(D ..1(11m o0000000W o
0 o0000000wG) A
O O O O O O 0 0 0
0 0 w N N n
00 ooNN
au V N
0 0 0 0 0 CD -A m
0(D 0 N 0 0 0 0 0 (No
RRR ppp
Ww9 WWW
� p p o 0
U1(71(Tl J Vj U; I Ut U1 DI �
p ) A A A
A A P o
000 000 ono .n
0 0 0 0 0 0 0 0 0 C:
o(P9 909 c CD(D a
o0o0 o0on o0on'� � ,d
A AAy AAA Daj (An (An vlw p,
NN N N NN N NN (D „
0 0 0 (D O O i6(D o O O f D m-
O O O o 0 0 0 Mi y
N
O N O N
A J J a W m Do O. co m w a D�1 D
0 0 0 If) 0 0 ID O O O n. U I
(U (D p tD cD r'p y (D (D W a. UI
(D (D (D (O(D(D tD(D(D N
(D(D(D (D (O(D T( (D
l,D(D (U(O i (D(O(D (DD(D
O O O
0 (n O
I
N O
O
CA 'T'pl
o I 1
n
aI - O
o 1 .
o I r9
N "t
UI �
N P
N N
co
D ul
i 3
3
w w
Ei
ry
U O C-)T
}U
N (D
J O
fj
O H O
III O
� v o
o
O aD
(o '1
I
O
UI
J N
N
UI
Z N
O
N
0 0 C) O O O (D O w U)0
A D) (3)
(3 0 0
CD C, N CD n
) D )
N 0 0 ID rn w
0 N
A A A iu
O
00o n
0 0 0
C
0 0 o O v
N U N
a o000 � o•
(n 01 'NO
_ 0 0 0 �w"tl ❑. ui
cD(D m O I p. Ui
(D (D co 7 .. N
C((D(D(wD r'fl C,
v
0
o
� I
I i
N
O •
1 pp r-F1
rOf '�•9n
En
N w w
cD ao(D O r-1
N
r C, J
O A rn F
Ut O
N �
W �n
D ul
3,
of w v)
ii Ac�D �� 3
n 0.V
c
m o00o Q. w'
(D
o' r)
T
J
r �\
O O Vi
N O
N � O
w O
o ` CDUl
CDO
C,
� O
(D t7
I � �
w
pI 0
of m C7 0.
rn
rn
o
v�
\( N
IJ
UI
O
m N
UI
O
U)
rn
FORTWORTH
TRANSPORTATION AND PUBLIC WORDS
PIPE RI�,?PORT FOR:
PROJECT NAME: Ye4 r • r 4c f 3-
CITY PROJECT NUMBER: (0/KSZ
WATER
PIPE LAID SIZE TYPE OF PIPE LF
Clan V p yc qq 17
FIRE HYDRANTS: VALVES(16" OR LARGER) IVIA
PIPE ABANDONED SIZE TYPE OF PIPE LF
N/A
DENSITIES: 4 A k C v4 W sr
NEW SERVICES: 1` Conna- 1�B eq
Cnnnec
SEWER
PIPE LAID SI TYPE OF PIPE LF
N D P t PC
5yr 16 PVC 76K
PIPE ABANDONED SIZE TYPE OF PIPE LF
/1/fi4
DENSITIES: cv% d
NEW SERVICES: pvc (.7C P-4
i
I TRANSPORTATION AND PUBLIC WORKS
I The City of Fort Worth- 1000 Throckmorton Street•Fort Worth,TR 76012-6311
(817)392-7941 1 Fax;(817)392-7845
i
I
FORTWORTH.
TRANSPORTATION AND PUBLIC WORKS
August 9, 2022
McClendon Construction Company, Inc
548 Memorial Plaza
Burleson,TX 76028
RE: Acceptance Letter
Project Name:2018 CIP Year 3—Contract 5
Project Type:water,sewer, paving
City Project No.: 101452
To Whom It May Concern:
On June 7, 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 June 14, 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 June 14, 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 817-
392-5565.
Sincerely,
Mary Hanna, Project Manager
Cc: Brian McGill, Inspector
Ron Cordova, Inspection Supervisor
Edward D'avila,Senior Inspector
Mary Hanna, Program Manager
Stream Water Group, Inc, Consultant
McClendon Construction Company, Inc, Contractor
N/A, Developer
File
E-Mail: TPW_Acceptance@fortworthtexas.gov
Rev.8/20/19
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.Tustin Blair, Vice President of McClendon
Construction Company, Incorporated, 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 there are no claims pending for personal injury and/or property damages;
On Contract described as;
2018 CIP Year 3—Contract 5 CPN 101452
B
Justin Blair
Subscribed and sworn before me on this day of
20 Z-
MISTY WEBB '
zJ 4�=Notary Public,state of taxes Notary Oublic in Tarrant
Comm.Expires 01-09-202e 9bunty,Texas
q•.....
Notary ID 12883807
Bond Number TXC611801
CONSENT OF
SURETY COMPANY
TO FINAL PAYMENT
PROJDCT. 2018 CIP Year 3 Contract 5 (Various Locations)
(name,ttdtim-m)
TO(Owner)
City of Fort Worth, Texas CONTRACT FOR: Construction
1000 Throckmorton Drive
Fort Worth, TX 76108
CONTRACTOR.: CONTRACT DATE:
McClendon Construction Company, Inc.
548 Memorial Plaza
Burleson, TX 76024
In accordance with the provisions of the Contract between the Owner and the Contractor as
indicated above,the(hem insert mime and Wdrres of Surety Co.)
Merchants Bonding Company [Mutual]
PO Box 14498
Des Moines, IA 50306-3498
SURETY COIIPANY,
on bond of(here insert name and addrew of Contrat.•tor)
McClendon Construction Company, Inc.
548 Memorial Plaza
Burleson, TX 76024 ,CONTRACTOR
hereby approves of the flual 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 invert name and
address of owned
City of Fort Worth, Texas
1000 Throckmorton Drive
Fort Worth, TX 76108 O%VNRR•
as sot forth In the said Surety Company's Dona.
IN WITNESS WHEREOF', Merchants Bonding Company [Mutual]
the Surety Companv hoe hereunto sot Ito hand this 4th _ day of Aucust 2022
Merchants Bonding Company [Mutual
5 rcW►nay
Siaoature ofAutheri presentath*
Elizabeth Ortiz
Attorney-in-Fact
ALE RC;HANTS�s
BONDING COMPANY
POWER OF ATTORNEY
Know All Persons By These Presents,that MERCHANTS BONDING COMPANY(MUTUAL)and MERCHANTS NATIONAL BONDING,INC.,
both being corporations of the State of Iowa(herein collectively called the"Companies")do hereby make,constitute and appoint,individually,
Ana Tomes;Andrew Addison;Betty J Reeh;Bryan K Moore;Elizabeth Ortiz;Michael D Hendrickson;Patricia Ann Lyttle;Patrick Coyle
their true and lawful Attorney(s)-in-Fact, to sign its name as surety(ies) and to execute, seal and acknowledge any and all bonds, undertakings,
contracts and other written instruments in the nature thereof, on behalf of the Companies in their business of guaranteeing the fidelity
of persons, guaranteeing the performance of contracts and executing or guaranteeing bonds and undertakings required or permitted in any
actions or proceedings allowed by law.
This Power-of-Attorney is granted and is signed and sealed by facsimile under and by authority of the following By-Laws adopted by the Board
of Directors of Merchants Bonding Company(Mutual)on April 23, 2011 and amended August 14, 2015 and adopted by the Board of Directors
of Merchants National Bonding,Inc.,on October 16,2015.
"The President, Secretary,Treasurer, or any Assistant Treasurer or any Assistant Secretary or any Vice President shall have power and authority
to appoint Attorneys-in-Fact, and to authorize them to execute on behalf of the Company, and attach the seal of the Company thereto, bonds and
undertakings,recognizances,contracts of Indemnity and other writings obligatory In the nature thereof,"
"The signature of any authorized officer and the seal of the Company may be affixed by facsimile or electronic transmission to any Power of Attorney
or Certification thereof authorizing the execution and delivery of any bond, undertaking, recognizance, or other suretyship obligations of the
Company,and such signature and seal when so used shall have the same force and effect as though manually fixed."
In connection with obligations in favor of the Florida Department of Transportation only,it is agreed that the power and aut hority hereby given to the
Attorney-in-Fact includes any and all consents for the release of retained percentages and/or final estimates on engineering and construction
contracts required by the State of Florida Department of Transportation. It is fully understood that consenting to the State of Florida Department
of Transportation making payment of the final estimate to the Contractor and/or its assignee, shall not relieve this surety company of any of
its obligations under its bond.
In connection with obligations in favor of the Kentucky Department of Highways only,it is agreed that the power and authority hereby given
to the Attorney-in-Fact cannot be modified or revoked unless prior written personal notice of such intent has been given to the Commissioner-
Department of Highways of the Commonwealth of Kentucky at least thirty(30)days prior to the modification or revocation.
In Witness Whereof,the Companies have caused this Instrument to be signed and sealed this 19th day of March 2021
UNt e��'o '���`��' CO�pO�° MERCHANTS BONDING COMPANY(MUTUAL)
POR9�': ° �p 0�,��q�� MERCHANTS NATIONAL BONDING,INC.
ro
1933
2003
�
�..� •... .•.:�gJ� d�aj`y.. `�d ° President
STATE OF IOWA ••�'"""""�� °° °°°
COUNTY OF DALLAS ss.
On this 19th day of March 2021 before me appeared Larry Taylor, to me personally known, who being by me duly sworn
did say that he is President of MERCHANTS BONDING COMPANY (MUTUAL) and MERCHANTS NATIONAL BONDING, INC.; and that the
seals affixed to the foregoing instrument are the Corporate Seals of the Companies;and that the said instrument was signed and sealed in behalf
of the Companies by authority of their respective Boards of Directors.
POLLY MASON
Commission Number 750576
b My Commission Expires
,oWP January 07, 2023 Notary Public
(Expiration of notary's commission
does not invalidate this instrument)
I,William Warner,Jr.,Secretary of MERCHANTS BONDING COMPANY(MUTUAL)and MERCHANTS NATIONAL BONDING,INC.,do hereby
certify that the above and foregoing is a true and correct copy of the POWER-OF-ATTORNEY executed by said Companies,which is still in full
force and effect and has not been amended or revoked.
In Witness Whereof,I have hereunto set my hand and affixed the seal of the Companies on this 4tl-i day of August 2022.
°,. °
o
2003 rye° ° 1933 Secretary
y'.
POA 0018 (1/20) """ °
BONDING COMPANY
EVITOR.`�AMA I`4OTICE
To obtain information or make a complaint:
You may contact your insurance agent at the telephone number provided by your insurance
agent.
You may call Merchants Bonding Company's toll-free telephone number for information or to
make a complaint at:
1-800-678-8171
You may contact the Texas Department of Insurance to obtain information on companies,
coverages, rights or complaints at:
1-800-252-3439
You may write the Texas Department of Insurance at:
P. O. Box 149104
Austin, TX 78714-9104
Fax: (512) 475-1771
Web: http://www.tdi.state.tx.us
E-mail: ConsumerProtection@tdi.state.tx.us
PREMIUM AND CLAIM DISPUTES: Should you have a dispute concerning your premium or
about a claim you should contact the agent first. If the dispute is not resolved, you may contact
the Texas Department of Insurance.
ATTACH THIS NOTICE TO YOUR POLICY: This notice is for information only and does not
become a part or condition of the attached document.
SUP 0032 TX (1/09)