HomeMy WebLinkAboutContract 59033-FP2FORT WORTH
-FP2
City Secretary
Contract No. 59033
Date Received 02/05/2024
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: Trails of Elizabeth Creek Phase 6
City Project No.: 103333
Improvement Type(s)
�
)17�
Contractor
Vice President
Water ❑x Sewer ❑x
Original Contract Price:
$817,403.50
Amount of Approved Change Order(,, $27,741.60
Revised Contract Amount:
Total Cost of Work Complete:
Title
Burnsco Construction, INC.
Company Name
Fabian Diaz (Jan 30, 202413:38 CST)
Project Inspector
Project Manager
Rebecca Owen IFeb 5. 2024 0811 CSTI
CFA Manager
-19.1-12,-
Lauren Prieur (Feb 5, 202408:26 CST)
TPW Director
Asst. City Manager
$845,145.10
$845,145.10
Jan 30, 2024
Date
Jan 30, 2024
Date
Jan 31, 2024
Date
Feb 5, 2024
Date
Feb 5, 2024
Date
Feb 5, 2024
Date
OFFICIAL RECORD Page 1 of 2
CITY SECRETARY
FT. WORTH, TX
Notice of Project Completion
Project Name: Trails of Elizabeth Creek Phase 6
City Project No.: 103333
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: 125 WD
Work Start Date: 5/8/2023
Completed number of Soil Lab Test: 387
Completed number of Water Test: 12
Days Charged: 149
Work Complete Date: 12/19/2023
Page 2of2
FoRTWORTH
CITY OF FORT WORTH
FINAL PAYMENT REQUEST
Contract Name TRAILS OF ELIZABETH CREEK
Contract Limits
Project Type WATER & SEWER IMPROVEMENTS
City Project Numbers 103333
DOE Number 3333
Estimate Number 1 Payment Number 1
City Secretary Contract Number
Contract Date
For Period Ending 12/19/2023
WD
Project Manager NA
Contractor BURNSCO CONSTRUCTION, INC.
6331 SOUTHWEST BLVD
FORT WORTH, TX 76132
Inspectors D. WATSON / F. DIAZ
Contract Time 6WD
Days Charged to Date 149
Contract is 100.00 Complete
Wednesday, January 24, 2024 Page 1 of 4
City Project Numbers 103333
Contract Name TRAILS OF ELIZABETH CREEK
Contract Limits
Project Type WATER & SEWER IMPROVEMENTS
Project Funding
UNIT I: WATER IMPROVEMENTS
DOE Number 3333
Estimate Number 1
Payment Number 1
For Period Ending 12/19/2023
Item
Description of Items
Estimated Unit
Unit Cost
Estimated
Completed
Completed
No.
Quanity
Total
Quanity
Total
1
8" WATER PIPE (CO #1)
4034 LF
$54.70
$220,659.80
4034
$220,659.80
2
8" GATE VALVE
12 EA
$1,800.00
$21,600.00
12
$21,600.00
3
FIRE HYDRANT
6 EA
$5,460.00
$32,760.00
6
$32,760.00
4
DUCTILE IRON WATER FITTINGS W/
1.515 TN
$7,300.00
$11,059.50
1.515
$11,059.50
RESTRAINT
5
1" WATER SERVICE (CO #1)
102 EA
$1,310.00
$133,620.00
102
$133,620.00
6
TRENCH SAFETY (CO #1)
4034 LF
$0.10
$403.40
4034
$403.40
7
CONNECTION TO EXISTING 4"-12" WATER
5 EA
$860.00
$4,300.00
5
$4,300.00
MAIN
8
8" WATERLINE LOWERING
6 EA
$5,010.00
$30,060.00
6
$30,060.00
9
WATER TESTING (EXCLUDING GEOTECH) (CO
4034 LF
$1.20
$4,840.80
4034
$4,840.80
#1)
Sub -Total of Previous Unit
$459,303.50
$459,303.50
UNIT 11: SANITARY SEWER IMPROVEMENTS
Item
Description of Items
Estimated Unit
Unit Cost
Estimated
Completed
Completed
No.
Quanity
Total
Quanity
Total
1
8" SEWER PIPE (SDR-26, ASTM D3034) (CO #1)
3344 LF
$55.00
$183,920.00
3344
$183,920.00
2
4" SEWER SERVICE (CO #1)
98 EA
$1,110.00
$108,780.00
98
$108,780.00
3
POST CCTV INSPECTION (CO #1)
3344 LF
$3.40
$11,369.60
3344
$11,369.60
4
T MANHOLE (CO #1)
15 EA
$3,770.00
$56,550.00
15
$56,550.00
5
8" SEWER PIPE, CSS BACKFILL
100 LF
$47.00
$4,700.00
100
$4,700.00
6
MANHOLE VACUUM TESTING (CO #1)
15 EA
$130.00
$1,950.00
15
$1,950.00
7
TRENCH SAFETY (CO #1)
3344 LF
$1.00
$3,344.00
3344
$3,344.00
8
TRENCH WATER STOP
3 EA
$400.00
$1,200.00
3
$1,200.00
9
CONNECTION TO EXISTING 4"-12" WATER
3 EA
$540.00
$1,620.00
3
$1,620.00
MAIN
10
T EXTRA DEPTH MANHOLE
33 VF
$180.00
$5,940.00
33
$5,940.00
11
12" STEEL CASING FOR SEWER SERVICE (CO
66 LF
$98.00
$6,468.00
66
$6,468.00
#1)
Sub -Total of Previous Unit $385,841.60
Wednesday, January 24, 2024
$385,841.60
Page 2 of 4
City Project Numbers 103333
Contract Name TRAILS OF ELIZABETH CREEK
Contract Limits
Project Type WATER & SEWER IMPROVEMENTS
Project Funding
Contract Information Summary
Original Contract Amount
Chanhe Orders
Change Order Number 1
Change Order Number 1
Total Contract Price
DOE Number 3333
Estimate Number 1
Payment Number 1
For Period Ending 12/19/2023
$817,403.50
$16,338.00
$11,403.60
$845,145.10
Total Cost of Work Completed $845,145.10
Less % Retained $0.00
Net Earned $845,145.10
Earned This Period $845,145.10
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
$845,145.10
Wednesday, January 24, 2024 Page 3 of 4
City Project Numbers 103333
Contract Name TRAILS OF ELIZABETH CREEK
Contract Limits
Project Type WATER & SEWER IMPROVEMENTS
Project Funding
Project Manager NA
Inspectors D. WATSON / F. DIAZ
Contractor BURNSCO CONSTRUCTION, INC.
6331 SOUTHWEST BLVD
FORT WORTH, TX 76132
DOE Number 3333
Estimate Number 1
Payment Number 1
For Period Ending 12/19/2023
City Secretary Contract Number
Contract Date
Contract Time 60 WD
Days Charged to Date 149 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 $845,145.10
Less % Retained $0.00
Net Earned $845,145.10
Earned This Period $845,145.10
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
$845,145.10
Wednesday, January 24, 2024 Page 4 of 4
(817) 392 - 7941 • Fax: (817) 392 - 7845
DocuSign Envelope ID: AE0268FD-127C-45B1-BCDC-6DDOA21ADC83
DEVELOPER -AWARDED -PROJECT CHANGE ORDER
REVIEWED
By Andrew Goodman at 12:02 pm, May 26, 2023
PROJECT NAME:
Trails of Elizabeth Creek Phase 6
CHANGE
CONTRACT:
Water, Sewer, Paving, Street Lights & Drainage Improvements
ORDER No:
CFA #
22-0138 CITY PARTICIPATION: No
CITY PROJECT #
103333
DOE #
N/A
1
FID #
30114-0200431-103333-EO7685
FILE #
26988
INSPECTOR:
Fabian Diaz Phone No: 817-223-2248
PROJECT MANAGER:
Andrew Goodman Phone No: 817-392-6251
CONTRACT UNIT
WATER SEWER PAVING
DRAINAGE
STREET LIGHTS CONTRACT
Developer Developer Developer
Developer
Developer DAYS
Cost I City Cost Cost City Cost Cost City Cost
Cost
City Cost
Cost City Cost
ORIGINAL CONTRACT
$442,965.50 I $374,438.00
$240,422.00
EXTRAS TO DATE
CREDITS TO DATE
CONTRACT TO DATE
$442,965.50 $0.00 I $374,438.00 $0.00 $0.00 $0.00
$240,422.00
$0.00
I $0.00 $0.00 60
AMOUNT OF PROP. CHANGE ORDER
$ 16,338.00 I $ 11,403.60
$ (9,449.00)
REVISED CONTRACT AMOUNT
$459,303.50 $0.00 I $385,841.60 $0.00 $0.00 $0.00
$230,973.00
$0.00
I $0.00 $0.00 60
TOTAL REVISED CONTRACT AMOUNT
PER UNIT
$459,303.50 $385,841.60 $0.00
$230,973.00
$0.00
REVISED COST SHARE
Dev. Cost: $1,076,118.10 Ci
TOTAL REVISED CONTRACT
$1,076,118.10
Revised: 10-12-2011 Page 1
DocuSign Envelope ID: AE0268FD-127C45B1-BCDC-6DDOA21ADC83
REVIEWED
By Andrew Goodman at 12:02 pm, May 26, 2023
You are directed to make the following changes in the contract documents:
CITY BID ITEM
PAY ITEM #
# QUANTITY
UNIT
ITEM DESCRIPTION
UNIT PRICE
TOTAL
Unit I: Water Improvements
1
3311.0241 128
LF
3311.0241 8" Water Pipe
$ 54.70
$
7,001.60
5
3312.2003 7
EA
3312.2003 1" Water Service
$ 1,310.00
$
9,170.00
6
3305.0109 128
LF
3305.0109 Trench Safety
$ 0.10
$
12.80
9
9999.0001 128
LF
9999.0001 Water Testing (Excluding Geotech)
$ 1.20
$
153.60
Total
$
16,338.00
Unit II: Sewer Improvements
1
3331.4115 -76
LF
3331.4115 8" Sewer Pipe (SDR-26, ASTM D3034)
$ 55.00
$
(4,180.00)
2
3331.3101 5
EA
3331.3101 4" Sewer Service
$ 1,110.00
$
5,550.00
3
3301.0002 -76
LF
3301.0002 Post -CCTV Inspection
$ 3.40
$
(258.40)
4
3339.1001 1
EA
3339.1001 4' Manhole
$ 3,770.00
$
3,770.00
6
3301.0101 1
EA
3301.0101 Manhole Vacuum Testing
$ 130.00
$
130.00
3
3305.0109 -76
LF
3305.0109 Trench Safety
$ 1.00
$
(76.00)
14
3301.0101 66
LF
12" Steel Casing For Sewer Service
$ 98.00
$
6,468.00
Total
$
11,403.60
Unit III: Storm Improvements
1
3349.5002 2
EA
3349.5002 10' Curb Inlet
$ 4,900.00
$
9,800.00
2
3349.5003 -2
EA
3349.5003 15' Curb Inlet
$ 6,600.00
$
(13,200.00)
5
3341.0309 -271
EA
3341.0309 36" RCP, Class III
$ 149.00
$
(40,379.00)
11
3341.1102 ill
EA
3341.1102 43 Box Culvert
$ 310.00
$
34,410.00
10
3305.0109 -160
EA
3305.0109 Trench Safety
$ 0.50
$
(80.00)
Total
$
(9,449.00)
TOTAL
$
18,292.60
REASONS FOR CHANGE ORDER
Unit l: 1 & 6; Unit ll: 1, 3, 4, 6, 7, 14
Reconciling DAP quantities
Unit 1: 2 & 5
Additional services added since the lot reconfiguration removed the use of existing services along Chaplin. Two additional services added
to the open space
Unit III: 1, 2
Revised inlet sizing to match the inlet capacity calculations
Unit lll: 5, 10, 11
Shift in lot layout revised storm design
NO CITY FUNDS INVOLVED IN THIS
CONTRACT.
DEVELOPER IS RESPONSIBLE FOR 100% OF THE CHANGE ORDER COST AND NO
REIMBURSEMENT FROM THE CITY
WILL BE SOUGHT BY THE DEVELOPER.
RECOMMENDED:
APPROVED: APPROVED:
('') PA%ing, Inc.
Fores Ae@al Estate Group Inc. Burnsco gyrg;.ton, Inc
o��igPe86S7:
B Y
t�A{�Dd�i �K.i
, J
B G= B 1l uw Grab s
y - - - -- Y
Name:
Ruby Rodriquez, PE
Name: Stephen Brim Name: Albert Grantges
Title:
Project Engineer
Title: Development Director Title: President
Revised: 10-12-2011 Page 2
FORTWORTH
TRANSPORTATION AND PUBLIC WORKS
PIPE REPORT FOR:
PROJECT NAME: Trails of Elizabeth Creek Ph 6
CITY PROJECT NUMBER: 103333
1 WATER
PIPE LAID SIZE TYPE OF PIPE
8" Main 8" PVC
FIRE HYDRANTS: 6
PIPE ABANDONED
DENSITIES:
NEW SERVICES:
PIPE LAID
8" sewer Main
4" Sewer service
PIPE ABANDONED
DENSITIES:
NEW SERVICES:
VALVES (16" OR LARGER)
SIZE TYPE OF PIPE
All Densities Passed
1" Water Service Copper
LF
4034
0
LF
102 total sevices
SEWER
SIZE TYPE OF PIPE LF
8" PVC 3346
4" PVC 2000
SIZE TYPE OF PIPE LF
All Densities Passed
4" sewer Service PVC
TRANSPORTATION AND PUBLIC WORKS
The City of Fort Worth • 1000 Throckmorton Street • Fort Worth, TX 76012-6311
98 total Services
FORTWORTH.
TRANSPORTATION AND PUBLIC WORKS
January 9, 2024
Burnsco Construction Inc
6331 Southwest Blvd
Benbrook, Texas 76132
RE: Acceptance Letter
Project Name: Trails of Elizabeth Creek Ph 6
Project Type: Water, Sewer
City Project No.: 103333
To Whom It May Concern:
On January 9, 2024 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 January 9, 2024,
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-
392-6251.
Sincerely,
Andrew Goodman, Project Manager
Cc: Fabian Diaz, Inspector
Donald Watson, Inspection Supervisor
Oscar Aguillon, Senior Inspector
Victor V Tornero Jr, Program Manager
LJA Engineering Inc, Consultant
Burnsco Construction Inc, Contractor
Forestar Real Estate Group, Inc , Developer
File
E-Mail: TPW_Acceptance@fortworthtexas.gov
Rev. 08/20/19
AFFIDAVIT
STATE OF TEXAS
COUNTY OF TARR-ANT
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;
Trails of Elizabeth Creek Ph. 6 - Water, Sanitary Sewer and Storm Drain
BY
Ab Grantges ntract Manager
Subscribed and sworn before me on this date 10th of January, 2024.
Notary Public
Tarrant County, Texas
KASSANDRA CANALES
€,TNotary Public, State of Texas
Comm. Expires 01-23-2027
Notary ID 134158873
CONSENT OF
SURETY COMPANY
TO FINAL PAYMENT
Conforms with the American Institute of
Architects, AIA Document G707
OWNER
❑
ARCHITECT
❑
CONTRACTOR
❑
SURETY
❑
OTHER
PROJECT:
(name, address)Trails of Elizabeth Creek Phase 6 - Water, Sanitary Sewer and Drainage Improvements
TO (Owner)
Fort Worth
TX
Bond No 022233352
FORESTAR (USA) REAL ESTATE GROUP, INC. AND ARCHITECT'S PROJECT NO:
CITY OF FORT WORTH
CONTRACT FOR:
14755 Preston Road, Suite 130 Trails of Elizabeth Creek Phase 6 - Water, Sanitary Sewer and
Drainage Improvements
Dallas TX 75254 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 nerve 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: j4'.0—
(Seal):
19th day of December, 2023
LIBERTY MUTUAL INSURANCE COMPANY
Surety Company
Signatu of Authorized Representative
SoDhinie Hunter
Title
Attorney -in -Fact
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: 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 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 attorney -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
Liberty Mutual Insurance Company
P, 1NSu/? P�1V INS& d %Nsut? The Ohio Casualty Insurance Company
tiJ o°aPO�r �n cu`�°aPORgr 4y SOP �oaPORgr y� West American Insurance Company
g� Fo c� vQ 3 Fo m w 3 Fo cr
Y 9s1912 q 3 i y� 1919`�� o s 1991 0 /j
nU+ �',yISACHo`'�.da �MAMPS'` -dam YS AVANP �aa� GG � .�9.��^ '� U
c /7 * )N �'H1 * t� dyr * *� By' m
"M State of PENNSYLVANIA CU
David M. Carey, Assistant Secretary 3
County of MONTGOMERY ss o E
U
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
o
0 75- > 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
there
in ein contained by signing on behalf of the corporations by himself as a duly authorized officer. > (9
�F
a) 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.
o � PASt a O
N
`�^ y ;g34ivCommonwealth of Pennsylvania - Notary seal =
J —
� p �s cy� "¢<;, �" Teresa Pastella, Notary Public N •—
" Montgomery County " "" yy e C W
+O-� fir: My commission expires March 28, 2025 B ,f',r,�pc✓ /�Q (/1"o O
�. Commission number 1126044 y'
N+•�:3fL ii C Member, Pennsylvania Association or Notaries eresa Pastella, Notary Public Q O
'} s o v
1 c 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 3 000
E•— I Insurance Company, and West American Insurance Company which resolutions are now in full force and effect reading as follows: a M
ARTICLE IV- OFFICERS: Section 12. Power of Attorney. - 00
0-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 0
C.)
President may prescribe, shall appoint such attorneys -in -fact, as may be necessary to act in behalf of the Corporation to make, execute, seal, acknowledge and deliver as surety 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 a L
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 m
Z o 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 attorney -in -fact under the f 0
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. LC) T
CL
ARTICLE All - 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 attorneys -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 19th_ day of December , 2023
Py 1NSURq P—SV INSpR tNSURq
AJ GoflPoR%, 5J `of0.Pop,; yy `VQ lxpop yr
J 2 Fo to ? Fo C' U ? Fo to
1912 o oy1919�o a 1991 0
d�9SSACHue`�dD y0IyAMP=D ( "NOIANP' D� By:
s�M * *�d Renee C. Llewellyn, Assistant Secretary
LMS-12873 LMIC OCIC WAIC Multi Co 02/21
r►Liberty
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: htta://www.tdi.texas.aov
E-mail: ConsumerProtection4,tdi.texas.aov
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.
NP 70 68 09 01
LMS-1529210/15
TEXAS
AVISO IMPORTANTE
Para obtener informacion o para someter una
queja:
Usted puede llamar al numero de telefono gratis
para informacion o para someter una queja al
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 al
1-800-252-3439
Puede escribir al Departamento de Seguros
de Texas Consumer Protection (I I I-1A)
P. O. Box 149091
Austin, TX 78714-9091
FAX # (512) 490-1007
Web: httn://www.tdi.texas.tiov
E-mail: ConsumerProtection4,tdi.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 condition del
documento adjunto.