HomeMy WebLinkAboutContract 55545-FP1-FP1
FORT WORTH.
City Secretary
Contract No. 55545
Date Received 03/29/2023
AT
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: Summer Creek Ranch Section XII Phase D
City Project No.: 102187
Improvement Type(s): Water x❑ Sewer x❑
Original Contract Price:
Amount of Approved Change Order(s):
Revised Contract Amount:
Total Cost of Work Complete:
�1
Contractor
Vice President
Title
Burnsco Construction, Inc.
Company Name
T/11y Gal-dhev
Project Inspector
C'J'
Project Manager
Re herre Diane Owen (M a r29. 202316:35 CDT)
CFA Manager
Lauren Prieur(M a r 29 202316:37 CDT)
TPW Director
Wll Gam Johnson f Ma 29. 202317:02 CDT)
Asst. City Manager
$815,291.50
$51,992.00
$867,283.50
$867,283.50
M a r 27, 2023
Date
M a r 27, 2023
Date
M a r 29, 2023
Date
Mar 29, 2023
Date
Mar 29, 2023
Date
M a r 29, 2023
Date
OFFICIAL RECORD
CITY SECRETARY Page 1 of 2
FT. WORTH, TX
Notice of Project Completion
Project Name: Summer Creek Ranch Section XII Phase D
City Project No.: 102187
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
Statement of Contract Time
Contract Time 170 WD Days Charged: 311
Work Start Date: 8/23/2021 Work Complete Date: 3/8/2023
Completed number of Soil Lab Test: 618
Completed number of Water Test: 18
Page 2of2
FoRTWoRTH
CITY OF FORT WORTH
FINAL PAYMENT REQUEST
Contract Name SUMMER CREEK RANCH SECTION XII PHASE D
Contract Limits
Project Type WATER & SEWER
City Project Numbers 102187
DOE Number 2187
Estimate Number 1 Payment Number 1 For Period Ending 3/23/2023
WD
City Secretary Contract Number Contract Time 17WD
Contract Date Days Charged to Date 311
Project Manager NA Contract is 100.00 Complete
Contractor BURNSCO CONSTRUCTION, INC.
6331 SOUTHWEST BLVD
FORT WORTH, TX 76132
Inspectors GLOVER / BARNES
Friday, March 24, 2023 Page 1 of 5
City Project Numbers 102187 DOE Number 2187
Contract Name SUMMER CREEK RANCH SECTION XII PHASE D Estimate Number I
Contract Limits Payment Number 1
Project Type WATER & SEWER For Period Ending 3/23/2023
Project Funding
WATER
Item
Description of Items
Estimated Unit
Unit Cost
Estimated
Completed
Completed
No.
Quanity
Total
Quanity
Total
1
TRENCH SAFETY
5750 LF
$0.10
$575.00
5750
$575.00
2
16" CONCRETE ENCASEMENT
40 LF
$60.00
$2,400.00
40
$2,400.00
3
DUCTILE IRON WATER FITTINGS
1.2 TN
$6,600.00
$7,920.00
1.2
$7,920.00
W/RESTRAINT
4
8" WATER PIPE (CO # 1)
5860 LF
$27.00
$158,220.00
5860
$158,220.00
5
FIRE HYDRANT
11 EA
$4,400.00
$48,400.00
11
$48,400.00
6
CONNECTION TO EXISTING 4"-12" WATER
3 EA
$1,000.00
$3,000.00
3
$3,000.00
MAIN
7
V WATER SERVICE (CO #1)
147 EA
$900.00
$132,300.00
147
$132,300.00
8
1" IRRIGATION SERVICE
1 EA
$900.00
$900.00
1
$900.00
9
1 1/2" IRRIGATION SERVICE
I EA
$1,350.00
$1,350.00
1
$1,350.00
10
8" GATE VALVE (CO #1)
25 EA
$1,330.00
$33,250.00
25
$33,250.00
11
36"X8" TAPPING SLEEVE & VALVE
I EA
$9,100.00
$9,100.00
1
$9,100.00
12
WATER TESTING
5750 LF
$0.60
$3,450.00
5750
$3,450.00
13
REMOVE & REPLACE ASPHALT PAVEMENT
27 SY
$115.00
$3,105.00
27
$3,105.00
14
AUTOMATIC FLUSHING VALVE (CO #1)
2 EA
$8,450.00
$16,900.00
2
$16,900.00
Sub -Total of Previous Unit
$420,870.00
$420,870.00
SEWER
Item
Description of Items
Estimated Unit
Unit Cost
Estimated
Completed
Completed
No.
Quanity
Total
Quanity
Total
1
Trench Safety
4491 LF
$1.00
$4,491.00
4491
$4,491.00
2
Trench Water Stop
11 EA
$300.00
$3,300.00
11
$3,300.00
3
4" Sewer Service (CO #1)
125 EA
$815.00
$101,875.00
125
$101,875.00
4
8" Sewer Pipe (CO #1)
1945 LF
$47.00
$91,415.00
1945
$91,415.00
5
8" Sewer Pipe, CSS Backfill
193 LF
$67.00
$12,931.00
193
$12,931.00
6
10" Sewer Pipe
2221 LF
$50.00
$111,050.00
2221
$111,050.00
7
10" Sewer Pipe, CSS Backfill (CO #1)
213 LF
$68.00
$14,484.00
213
$14,484.00
8
Epoxy Manhole Liner
32.5 VF
$260.00
$8,450.00
32.5
$8,450.00
9
4' Manhole
15 EA
$3,500.00
$52,500.00
15
$52,500.00
10
4' Extra Depth Manhole
46.6 VF
$150.00
$6,990.00
46.6
$6,990.00
11
4' Drop Manhole Over Existing Line
I EA
$6,200.00
$6,200.00
1
$6,200.00
Friday, March 24, 2023 Page 2 of 5
City Project Numbers 102187 DOE Number 2187
Contract Name SUMMER CREEK RANCH SECTION XII PHASE D Estimate Number 1
Contract Limits Payment Number 1
Project Type WATER & SEWER For Period Ending 3/23/2023
Project Funding
12 4' Manhole Over Existing Line
1 EA
$4,300.00
$4,300.00
1 $4,300.00
13 4" Sewer Service on Existing Line
7 EA
$2,300.00
$16,100.00
7 $16,100.00
14 Testing (Excluding Geotech)
4491 LF
$2.50
$11,227.50
4491 $11,227.50
15 Connection to Existing Manhole
--------------------------------------
1 EA
$1,100.00
$1,100.00
1 $1,100.00
Sub-Total of Previous Unit
$446,413.50
$446,413.50
Friday, March 24, 2023 Page 3 of 5
City Project Numbers 102187
Contract Name SUMMER CREEK RANCH SECTION XIi PHASE D
Contract Limits
Project Type WATER & SEWER
Project Funding
Contract Information Summary
Original Contract Amount
Change Orders
Change Order Number 1
Change Order Number 1
Total Contract Price
DOE Number 2187
Estimate Number 1
Payment Number 1
For Period Ending 3/23/2023
$815,291.50
$36,460.00
$15,532.00
$867,283.50
Total Cost of Work Completed $867,283.50
Less % Retained $0.00
Net Earned $867,283.50
Earned This Period $867,283.50
Retainage This Period $0.00
Less Liquidated Damages
Days @ / Day
LessPavement Deficiency
Less Penalty
Less Previous Payment
Plus Material on Hand Less 15%
Balance Due This Payment
$0.00
$0.00
$0.00
$0.00
$0.00
$867,283.50
Friday, March 24, 2023 Page 4 of 5
City Project Numbers 102187
Contract Name SUMMER CREEK RANCH SECTION XII PHASE D
Contract Limits
Project Type WATER & SEWER
Project Funding
Project Manager NA
Inspectors GLOVER / BARNES
Contractor BURNSCO CONSTRUCTION, INC.
6331 SOUTHWEST BLVD
FORT WORTH, TX 76132
DOE Number 2187
Estimate Number 1
Payment Number 1
For Period Ending 3/23/2023
City Secretary Contract Number
Contract Date
Contract Time 170 WD
Days Charged to Date 311 WD
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 $867,283.50
Less % Retained $0.00
Net Earned $867,283.50
Earned This Period $867,283.50
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
$867,283.50
Friday, March 24, 2023 Page 5 of 5
■
}\
30
/
\
}
§
}
(
0
\
/
X
u
{
\
\
/
)
±
\
/
o
§
E
§
2
\
\
G
\
{)
\
2
}
(
)
5/
§
}
/
u
00
b
e
e
d
±
E
/
±
±
3
#
\
±
\
%
\
±
§
§
a-
o
ol
51
c
R
m
122
§
}
0
0
§°
e
0
§
a
k\\
z
G
8
\j-
°�
\
§CL,
°
{
§
§
_
)
�
§�
}k
q
\ k
k
\
k
#
/
) §
§
\
§
\
..
_
\
k
-
0
ee\
e
m
]
\\)
/
(
)
)
\ LU
/
>
:
-
[
0
o
0
00P[b8!
/
o
±
§
m
_
j
<
e
»
&
e
)
m
)
\
w
0
0
\
j
0000
0
0 o
O
0 0
o 0
0
0
0 0
o 0
0 o
0 0
O o
o O
0 o
o 0
O o
0 0
0 0
0 0
o 0 0
0 0 0
O m
O O
N
M
m
N
N
O
O
m
Q� N
O N
m O
mo N
0 0
(O N
N
M 7
N tp
N O
M t0 W
N
N M
(O
e- M
.--
N
r
m
V
Nas
N r
M
M
Q
O
f-
fA
fA EA
fA
EA EA
EA
tp Fp
fA fA
fA fH
fi3 fA
fA fA
fA (fl
� � fA
W
o
o o
O
O O
O
co
o O
o 0
o O
o 0
o 0
o 0
U
o
0 0
0
0 0
0
0 0
0 o
0 0
o 0
0 0
0 0
0 0
LL'
I--Ooo
N
O M
m
tf)1�
V'
W
(O
vvvNm
( I
m o
m a
Oo0o
O o
o t
vvoO
O
N o
LL
m M
V
N
M
M ID
<} cq
F
m
v N
Z
7
EA
69 EA
fA
fA fA
f9
fA IA
EA fA
Nf to
to to
fA fA
V3 fA
fA fA
v
c
M
J
LL
�
>
N
>
Y
U ❑
m
IL
O
U
m
>
oc�
Q
_ _
_ _
�.
O>
V Q
m
No
N N
O N
d
O
N
N
o
�
T>
j
w
U
U U
U U
U U
a n�
o H
ce u)
U)
m
v
LL
`m o
a a
a a
o a
o 0
0
,o F
❑
O(D
U
3 0_
U U
U U
m U
u
o°
v u
x 0
KK2CL�����
c
>
W
M
M
E
O
N N
V
O N~~❑
co)
a
a
vu)
N C
X
vo
0
n
Z
W
0
0
4-
Z
LL
J
Q Q
W w
Q
W
Q LL
W J
LL
J
LL LL
J J
LL LL
J J
LL LL
J J
Q Q}}}
}
LL Q
J
7
W W
w w
w w
Lll
OIco
N
N
�!
N n
co
O n
N N
N
o M
W
N
Q
M
0
#
W
M M
M
m
N
i!1
N m
M m
M
m O
N
OJ m
F
N
N
o O
O O
O
O
0
N
0 0
N N
0 0
M
0 0
M 0
0 0
N
0 0
N N
0 0
N N
0 0
❑
O
N M
M a
a
O O
O O
7 O
O O
O O
O O
o 0
m
1-
M
N N
M
m
M M
M
a
V
M
V M
M M
M M
M M
M M
M M
M M
M m
M m
F
M
M
M M
m
M M
M M
M
M
M M
M M
M M
M M
M m
M m
m m
m m
m m
m m
m m
m m
m m
m m
U
w
W
O
0
7 �
M �O
� N
M V
h OJ
Q
e- N
N N
M M
M M
M M
a
N
N
�
C
m
3
m
w G
W h
❑ N
0 K
w
0
Z
Q
U
It
O
LL
U)
Z
0
Q
w
FnC�
Zw
o(L
�O
ww
it w
to ❑
IX w
way
o}
w CO
0f-
0
❑D
h O
U U)
W
F m
Z J
o3
UI Y
Z W
W ~
o�
Z LL
Z f-
Z
❑ W
z�
W
LL �
U �
Z K
W
0
it
a
a
Q
E
z
FORTWORTH
TRANSPORTATION AND PUBLIC WORKS
PIPE REPORT FOR:
PROJECT NAME: Summer Creek Ranch Section XII Phase D
CITY PROJECT NUMBER: 102187
WATER
PIPE LAID
SIZE
TYPE OF PIPE
LF
C900 PVC Water Pipe
8"
C900 PVC
5,860
FIRE HYDRANTS: 11
VALVES (16" OR LARGER)
N/A
PIPE ABANDONED
SIZE
TYPE OF PIPE
LF
N/A
N/A
N/A
N/A
DENSITIES:
Densities Taken and Uploaded to Accela
NEW SERVICES:
l"
(147) 1" Water Service (DOM)
2,205
l"
(1) V Water Service (IRR)
10
1 1/2"
(1) 1 1/2" Water Service (IRR)
10
SEWER
PIPE LAID
SIZE
TYPE OF PIPE
LF
SDR-26 PVC Sewer Pipe
8"
SDR-26 PVC Sewer Pipe
1,945
SDR-26 PVC Sewer Pipe CSS
8"
SDR-26 PVC Sewer Pipe
193
SDR-26 PVC Sewer Pipe
10"
SDR-26 PVC Sewer Pipe
2,221
SDR-26 PVC Sewer Pipe CSS
10"
SDR-26 PVC Sewer Pipe
213
PIPE ABANDONED
SIZE
TYPE OF PIPE
LF
N/A
N/A
N/A
N/A
DENSITIES:
Densities Taken and Uploaded to Accela
NEW SERVICES:
4"
125 New 4" Sewer Services
1,875
TRANSPORTATION AND PUBLIC WORKS
The City of Fort Worth • 1000 Throckmorton Street • Fort Worth, TX 76012-6311
(817) 392 - 7941 • Fax: (817) 392 - 7845
FORTWORTH.
TRANSPORTATION AND PUBLIC WORKS
March 23, 2023
Burnsco Construction, Inc
6331 Southwest Blvd.
Benbrook, TX 76132
RE: Acceptance Letter
Project Name: Summer Creek Ranch Section XII Phase D
Project Type: Water & Sewer
City Project No.: 102187
To Whom It May Concern:
On March 17, 2023 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 March 23, 2023. 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 March 23, 2023, 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-
392-6251.
Sincerely, p
Andrew Goodman, Project Manager
Cc: Troy Gardner, Inspector
Gary Deyon, Inspection Supervisor
Edward D'avila, Senior Inspector
Victor Tornero, Program Manager
UA Engineering, Inc., Consultant
Gilco Contracting, Inc., Contractor
Forestar (USA) Real Estate Group, Inc., 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 Ab Grantges,
Contract Mgr, 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;
Summer Creek Ranch 12D - Water, Sanitary Sewer and Storm Drain
BY 4
Ab Grant s, Contract Manager
Subscribed and sworn before me on this date 27th of March, 2023.
SPpr"Py EMMA TURNER
Notary Public, State of Texas
Notary Public=*. •_ My Commission Expires
Tarrant County, Texas "rF a, E,e. August 12, 2025
NOTARY ID 13326419
CONSENT OF
SURETY COMPANY
TO FINAL PAYMENT
Conforms with the American Institute of
Architects, AIA Document G707
OWNER
❑
ARCHITECT
❑
CONTRACTOR
❑
SURETY
❑
OTHER
Bond No 022226700
PROJECT:
(name, addreSS)Summer Creek Ranch Section 12 Phase D - Water, Sanitary Sewer and Drainage Improvements
TO (Owner)
Fort Worth
TX
FORESTAR (USA) REAL ESTATE GROUP, INC. AND7 ARCHITECT'S PROJECT NO:
CITY OF FORT WORTH CONTRACT FOR:
14755 Preston Road, Suite 130 Summer Creek Ranch Section 12 Phase D - Water, Sanitary Sewer
and Drainage Improvements
Dallas TX 75254 --J CONTRACT DATE:
CONTRACTOR: BURNSCO CONSTRUCTION, INC.
In accordance with the provisions of the Contract between the Owner and the Contractor as indicated above, the
(here 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)
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
Attest:
(Seal):
17th day of March, 2023
LIBERTY MUTUAL INSURANCE COMPANY
Surety Company
Signat 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
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: 8206467-022020
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 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, Don E.
Cornell; Joshua Saunders; Kelly A. Westbrook; Mikaela Peppers; Ricardo J. Reyna; Robbi Morales; Sophinie Hunter; Tina McEwan; Tonie Petranek
all of the city of Dallas state of TX each individually if there be more than one named, its true and lawful attomey-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 23rd day of April , 2021 .
V)
N
C
t0
t`u State of PENNSYLVANIA
a, County of MONTGOMERY ss
E
o c�a
Liberty Mutual Insurance Company
P. 1NSUy P�SV INSVR a \Nsfi, q The Ohio Casualty Insurance Company
AJ ooaFol7yCi hJ C.oapoRgTF.9y \VP' 4oV Pof? y0 West American Insurance Company
J 3 o cn Q?
�1912y0 oy1919�o e 1991 0
*N5 NAMPS��,da� YS��NOtANP�,daS' B /Lr�I✓rt`?
1 * > M * > y
David M. Carey, Assistant Secretary
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 a=i
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
therein contained by signing on behalf of the corporations by himself as a duly authorized officer. I @
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.
tq��oNPJ�c4 Commonwealth of Pennsylvania - Notary Seal
Teresa Pastella, Notary Public BQ-aLJ
OF Montgomery County
My commission expires March 28, 2025 By:
" YLVt*Member,PennsylvaniaCommission Assocationof Notaries Teresa Pastella, Notary Public
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
Insurance Company, and West American Insurance Company which resolutions are now in full force and effect reading as follows:
ARTICLE 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 to such limitation as the Chairman or the
President may prescribe, shall appoint such attomeys-in-fact, as may be necessary to act in behalf of the Corporation to make, execute, 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 respective 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 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 attomey-in-fact under 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.
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, 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, 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 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.
I, 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.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seals of said Companies this 17th day of March , 2023 .
P%- %NSURq P�IV INS& � %NSU.0
jr°oaPo�royc� QJaooaPo�ro�g2� \v �40Rp0Ry��y�
U to 1912 0 o o rn J `-•�
y 1919 � o 11
a 990
Cf�9sSACHUS�.da3O yONA MPS�`e ate' Y �NP a� By:
brAN
*�d s�M 1 d Renee C. Llewellyn, Assistant Secretary
LMS-12873 LMIC OCIC WAIC Multi Co 02121
�ZO
Oq
O N
�o?
O CCV-2
l00
00
o�
c
ca =
a�
TEXAS
IMPORTANT NOTICE
To obtain information or make a complaint:
You may call toll -free for information or to
make a complaint at
1-877-751-2640
You may also write to:
2200 Renaissance Blvd., Ste. 400
King of Prussia, PA 19406-2755
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
Consumer Protection (I I I-1A)
P. O. Box 149091
Austin, TX 78714-9091
FAX: (512) 490-1007
Web: http://www.tdi.texas.gov
E-mail: ConsumerProtectionna tdi.texas.gov
PREMIUM OR CLAIM DISPUTES:
Should you have a dispute concerning your
premium or about a claim you should first
contact the agent or call 1-800-843-6446.
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.
NP70680901
LMS-15292 10/15
TEXAS
AVISO IMPORTANTE
Para obtener informacion o para someter una
queja:
Usted puede llamar at numero de telefono gratis
para informacion o para someter una queja at
1-877-751-2640
Usted tambien puede escribir a:
2200 Renaissance Blvd., Ste. 400
King of Prussia, PA 19406-2755
Puede comunicarse con el Departamento de
Seguros de Texas para obtener informacion
acerca de companias, coberturas, derechos o
quejas at
1-800-252-3439
Puede escribir at Departamento de Seguros
de Texas Consumer Protection (I I I-1A)
P. O. Box 149091
Austin, TX 78714-9091
FAX # (512) 490-1007
Web: hUp://www.tdi.texas.gov
E-mail: Con sumerProtectionntdi.texas gov
DISPUTAS SOBRE PRIMAS O RECLAMOS:
Si tiena una disputa concerniente a su prima o a
un reclamo, debe comunicarse con el agente o
primero. Si no se resuelve la disputa, puede
entonces comunicarse con el departamento (TDI)
UNA ESTE AVISO A SU POLIZA:
Este aviso es solo para proposito de informacion
y no se convierte en parte o condicion del
documento adjunto.