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HomeMy WebLinkAboutContract 57635-A1FP2FP2 City Secretary 57635 Al Contract No. FORT WORTH. Date Received 7/11/2024 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: Tradition Phase 4C City Project No.: 103628 Improvement Type(s): ❑ Paving 0 Drainage ❑ Street Lights ❑ Traffic Signals Original Contract Price: $1,247,512.50 Amount of Approved Change Order(s) $100,182.50 Revised Contract Amount: $1,347,695.00 Total Cost of Work Complete: $1,347,695.00 x.� Jul 10, 2024 Kevin GerstenKern (Jul 10, 202414:00 CDT) Contractor Date Executive VP of Operations Title PCI Construction Company Name i70et <Wva Joey Silva (Jul 11, 202408:18 CDT) Jul 11, 2024 Project Inspector Date 4-a4l� Sa"' /OIL2�.' PC' J u 111, 2024 Project Manager Date J u 111, 2024 Rebecca Owen (Jul 11, 202411:42 CDT) CFA Manaqer Date Jul 11, 2024 TPW Director Date cv� J u 112, 2024 Asst. City Manager Date OFFICIAL RECORD CITY SECRETARY FT. WORTH, TX Page 1 of 2 Notice of Project Completion Project Name: Tradition Phase 4C City Project No.: 103628 City's Attachments Final Pay Estimate x❑ Change Order(s): ❑x Yes ❑ N/A Contractor's Attachments Affidavit of Bills Paid Consent of Surety Statement of Contract Time Contract Time 230 WD Work Start Date: 3/6/2023 Completed number of Soil Lab Test: 1048 Completed number of Water Test: 18 Days Charged: 282 WD Work Complete Date: 7/3/2024 Page 2of2 FoRTWORTH CITY OF FORT WORTH FINAL PAYMENT REQUEST Contract Name TRADITION, SOUTH PHASE 4C Contract Limits Project Type DRAINAGE City Project Numbers 103628 DOE Number 3628 Estimate Number 1 Payment Number 1 City Secretary Contract Number Contract Date 3/6/2023 For Period Ending Project Manager NA Contractor PCI CONSTRUCTION, INC. P.O. BOX 2967 McKINNEY , TX 75070 Inspectors M.GLOVER / J.DAVIS Contract Time Days Charged to Date Contract is 100.00 7/3/2024 WD 23WD 282 Complete Tuesday, July 9, 2024 Page 1 of 4 City Project Numbers 103628 DOE Number 3628 Contract Name TRADITION, SOUTH PHASE 4C Estimate Number I Contract Limits Payment Number 1 Project Type DRAINAGE For Period Ending 7/3/2024 Project Funding UNIT lII: STORM DRAIN Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total 33 MEDIUM RIPRAP, DRY (CO #1) 83 SY $97.00 $8,051.00 83 $8,051.00 34 TRENCH SAFETY (CO #1) 3837 LF $0.20 $767.40 3837 $767.40 35 CONCRETE COLLAR (CO #1) 5 EA $477.00 $2,385.00 5 $2,385.00 36 21" RCP, CLASS III (CO #1) 325 LF $73.10 $23,757.50 325 $23,757.50 37 24" RCP, CLASS III (CO #1) 840 LF $88.20 $74,088.00 840 $74,088.00 38 27" RCP, CLASS III (CO #1) 301 LF $98.00 $29,498.00 301 $29,498.00 39 36" RCP, CLASS III (CO #1) 462 LF $157.80 $72,903.60 462 $72,903.60 40 42" RCP, CLASS III (CO #1) 295 LF $218.00 $64,310.00 295 $64,310.00 41 48" RCP, CLASS II 199 LF $274.80 $54,685.20 199 $54,685.20 42 4' STORM JUNCTION BOX 4 EA $5,456.00 $21,824.00 4 $21,824.00 43 Y STORM JUNCTION BOX 3 EA $7,986.00 $23,958.00 3 $23,958.00 44 T MANHOLE RISER (CO #1) 2 EA $2,678.00 $5,356.00 2 $5,356.00 45 10' CURB INLET 16 EA $7,148.00 $114,368.00 16 $114,368.00 46 15' CURB INLET 4 EA $9,306.00 $37,224.00 4 $37,224.00 47 10' X 5' JUNCTION BOX I EA $13,863.00 $13,863.00 1 $13,863.00 48 SINGLE 8' X Y R.C.B. HEADWALL 1 EA $19,871.00 $19,871.00 1 $19,871.00 49 CONNECT TO EXISTING 9' X 5' R.C.B. I EA $3,199.00 $3,199.00 1 $3,199.00 50 TX T R.C.B., CLASS III 878 LF $350.40 $307,651.20 878 $307,651.20 51 8' X 3' R.C.B.,CLASS III 360 LF $643.60 $231,696.00 360 $231,696.00 52 9' X 5' R.C.B., CLASS III Ill LF $901.60 $100,077.60 111 $100,077.60 53 CONCRETE APRON 10 SY $132.00 $1,320.00 10 $1,320.00 55 12' X 12' JUNCTION BOX (CO #1) 1 EA $22,890.00 $22,890.00 1 $22,890.00 56 20' CURB INLET (CO #1) 1 EA $11,504.00 $11,504.00 1 $11,504.00 57 27" SLOPED END HEADWALL (CO #1) 1 EA $5,289.00 $5,289.00 1 $5,289.00 58 SINGLE TX Y R.C.B. HEADWALL (CO #1) 2 EA $9,387.00 $18,774.00 2 $18,774.00 59 TX Y R.C.D., CLASS III (CO #1) 87 LF $320.50 $27,883.50 87 $27,883.50 60 CONCRETE FLUME (6' WIDTH) (CO #1) 327 SY $146.00 $47,742.00 327 $47,742.00 61 REMOVE EX. 2 1 " RCP & 10' CURB INLET ((CO 1 EA $2,759.00 $2,759.00 1 $2,759.00 #1) Sub -Total of Previous Unit $1,347,695.00 $1,347,695.00 Tuesday, July 9, 2024 Page 2 of 4 City Project Numbers 103628 Contract Name TRADITION, SOUTH PHASE 4C Contract Limits Project Type DRAINAGE Project Funding Contract Information Summary Original Contract Amount Chanhe Orders Change Order Number 1 DOE Number 3628 Estimate Number 1 Payment Number 1 For Period Ending 7/3/2024 $1,247,512.50 $100,182.50 Total Contract Price $1,347,695.00 Total Cost of Work Completed $1,347,695.00 Less % Retained $0.00 Net Earned $1,347,695.00 Earned This Period $1,347,695.00 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 $1,347,695.00 Tuesday, July 9, 2024 Page 3 of 4 City Project Numbers 103628 Contract Name TRADITION, SOUTH PHASE 4C Contract Limits Project Type DRAINAGE Project Funding Project Manager NA Inspectors M.GLOVER / J.DAVIS Contractor PCI CONSTRUCTION, INC. P.O. BOX 2967 MCKINNEY , TX 75070 DOE Number 3628 Estimate Number 1 Payment Number 1 For Period Ending 7/3/2024 City Secretary Contract Number Contract Date 3/6/2023 Contract Time 230 WD Days Charged to Date 282 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 $1,347,695.00 Less % Retained $0.00 Net Earned $1,347,695.00 Earned This Period $1,347,695.00 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 $1,347,695.00 Tuesday, July 9, 2024 Page 4 of 4 DEVELOPER -AWARDED -PROJECT CHANGE ORDER PROJECT NAME: Tradition - Phase 4C CONTRACT: (A) Water/Sewer/Storm Drain, (B) Pavinq, (C) Street Lights CFA# 22-0057 CITY PARTICIPATION: 0% CITY PROJECT # 103628 FID # 30114-0200431-103628-EO7685 FILE # X-27070 INSPECTOR: Jesse Davis Phone No: 817-863-3705 PROJECT MANAGER: Arash Emami Saleh Phone No: 817-392-2373 beveloper Cost WATER City Cost $0.00 ORIGINAL CONTRACT $802,748.80 EXTRAS TO DATE CREDITS TO DATE CONTRACT TO DATE I $802,748.80 AMOUNT OF PROP. CHANGE ORDER I $4,284.00 REVISED CONTRACT AMOUNT I $807,032.80 TOTAL REVISED CONTRACT AMOUNT PER UNIT $807,032.8( REVISED COST SHARE IDev. Cost: TOTAL REVISED CONTRACT $0.00 $0.00 SEWER Developer Cost City Cost $1,668,607.40 $0.00 $1,668,607.40 I $0.00 $7,154.50 $1,675,761.90 I $D.00 $1,675,761.90 $5,909,928.14 You are directed to make the following changes in the docu ents CITY BID ITEM PAY ITEM # # rQntract UANTITY UNIT NEW 1 EA WATER TOTAL 3301.0002 15 (220) LF 3305.0109 17 (220) LF 1 3305.0113 18 2 EA 1 3331.4115 20 (241) LF 1 3331.4116 21 7 LF 3331.4201 22 (557) LF 3331.4208 23 521 1 LF I 3331.4205 1 24 27 1 LF 1 3339.0001 I 27 1 2 VF 1 3339.1003 1 29 1 (32) VF I 3305.1104 1 31 1 15 I LF I 1 3331,3201 I NEW 1 2 1 EA 3331.4205 I NEW 1 23 1 LF SEWER TOTALI 3137.0104 33 49 SY I 3305.0109 34 (107) LF 3305.0112 35 (3) EA REVIEWED By Arash Emami Sa/eh at 9:45 am, Jul 05, 2024 CHANGE ORDER No: 1 CONTRACT UNIT DRAINAGE PAVING STREET Developer I Developer Cost City Cost Developer Cost City Cost Cost $1,247,512.50 $0.00 $1,772,043.00 $0.00 $217,465.44 1 $1,247,512.50 $100,182.50 Ij $1,347,695.00 $0.00 I $1,772,043.00 $0.00 $217,466.44 $90,030.00 I $0.00 $0.00 $1,862,073.00 I $0.00 I $217,465.44 $1,347,695.00 $5,910,028.14 LIGHTS City Cost $0.00 $0.00 $0.00 $1,862,073.00 I $217,465.44 City Cost: $0.00 CONTRACT DAYS 230 230 0 230 ITEM DESCRIPTION UNIT PRICE TOTAL Adjust Water Valve Rim to Grade $4,284.00 $4.284.00 $4.284.00 Post -CCTV Inspection $3.70 ($814.00) Trench Safety $0.60 ($132.00) Trench Water Stops $1,290.00 2,580.00 8" SDR-26 PVC Sewer P* e I $61.70 ($14.869.70) 8" PVC Sanitary Sewer Pipe w/CSS Backfill I $90.30 $632.10 10" SDR-26 PVC Sewer Ppe 1 $87.40 ($48.681.80) 12" SDR-26 PVC Sewer Pipe 1 $110.001 $57,310.00 10" DIP Sewer Pipe 1 $170.701 $4,608.90 Epoxy Manhole Liner 1 $531.001 $1,062.00 4' Extra De th Manhole Sther 1 $172.001 (S5,504.00) 24" Steel Casing By Than Open Cut 1 $219.001 $3,285.001 6" Sewer Service (SDR-35 PVC 1 $1,884.001 $3,768.00 10" DIP Sewer Pipe w/CSS Bacli I $170.001 $3,910.00 I 1 $7154.50 Medium R'q?rap, dry I $97.001 $4\ 53.00 Trench Safe' 1 $0.201 ($21.40) Concrete Collar 1 $477.001 ($1,431.00) Revised: 10-12-2011 Page 1 3341.0201 36 10 LF 21" RCP, Class III $73.10 $731.001 3341.0205 37 (22) LF 24" RCP, Class III $88.20 ($1,940.40) 3341.0208 38 41 LF 27" RCP, Class III $98.00 $4,018.001 3341.0309 39 (199) LF 36" RCP, Class III $157.80 ($31.402.20)1 3341.0402 40 (3) LF 1 42" RCP, Class III I $218.00 ($654.00)1 3349.0102 44 4) EA I 4' Manhole Riser I $2,678.00 ($10,712.00) 9999.0002 NEW 1 EA 1 12' x 12' Junction Box 1 $22.890.001 $22,890.00 3349.5003 NEW 1 EA 1 20' Curb Inlet 1 $11,504.001 $11,504.00 3349.4106 NEW 1 I EA I 27" Sloped End Headwall 1 $5,289.001 $5,289.00 9999.0008 1 NEW 2 1 EA I Sinqle 4' x 3' R.C.B. Headwall 1 $9.387.001 $18,774.00 9999.0009 1 NEW 87 LF I 4' x 3' R.C.B., Class III 1 $320.501 $27,883.50 9999.0010 NEW I 327 SY I Concrete Flume (6' Width) 1 $146.001 $47,742.001 9999.0011 NEW 1 1 I EA I Remove Ex. 21" RCP & 10' Curb Inlet 1 $2,759.001 $2,759.001 DRAINAGE TOTALI 1 1 $100,182.501 3213.0506 63 2 EA I P-1 Ramp 1 $2,550.001 $5.100.001 NEW 246 SY I 10" Concrete Pavement (Arterial) 1 $200.001 $49,200.00 NEW 276 SY I 8" Lime Treated Subqrade f Arterial) 1 $25.001 $6,900.00 NEW 5 Ton I Hydrated Lime (a) 36lbs/SY (Arterial) 1 $400.00 $2,000.00 NEW 69 1 SY I Remove Ramps & Sidewalk 1 $15.00 $1,035.00 NEW 231 I LF I Remove Concrete Curb & Gutter 1 $15.001 $3,465.00 1 NEW 118 I LF I 10' Conc Sidewalk 1 $95.001 $11,210.00 I NEW 278 I LF I Connect to Existing Pavement 1 $40.001 $11,120.00 PAVING TOTALI 1 1 $90,030.001 TOTAL I $201.651.001 REASONS FOR CHANGE ORDER 1. Added Turn Lane on Winding Meadows Drive 2. Added Detention Pond per Approved Drainage Study & associated revisions to Drainage and Sewer Quantities NO CfTY>'itfW$ WYOLVEO IN THIS CONTRACT. DEVELOPER IS RESPONSrSLE FOR. 100% DF THE G-RAN15E OFWER COST AND NO REIMSURSEMENT FROM THE CITY WILL BE S4UGIiT DY THE DEVELOPER, RECU'fl MADIIED.- APPROVEa. APPROVED: APPROVED: Gcodvist ar.6 Marsh", Inc- HT Hwy- PI" !nett a RP34 UC R f Gwfs, fon, frc. f %.. see attached B)r 1AL By, By-, 'By Name: Matt Saacke, P.E. tame: Robert Witte Name: Stryker NichOts rue: art Engineer T-itfe: Sr. 'Managing Director ride: 'Tide; Project Manager REVIEWED By Arash Emami Sa/eh at 9:45 am, Jul 05, 2024 Revised: 10-12-2011 Page 2 DocuSign Envelope ID: 55AA667A-5EB8-4DDE-A964-5403DF927292 HT HWY 114 DEVELOPMENT LP By: HT Hwy 114 Development LLC, its general partner By: HT Hwy 114 LP, its sole member By: Hines Hwy 114 LLC, its general partner By: Hines Hwy 114 Associates LP, its sole member By: Hines Investment Management Holdings Limited Partnership, its general partner DS DocuSd b By: y: �o [�8'Wbert W. Witte Title: Senior Managing Director REVIEWED By Arash Emami Saleh at 9:45 am, Jul 05, 2024 FORTWORTH. TRANSPORTATION AND PUBLIC WORKS July 5, 2024 PCI Construction 405 Interchange St. McKinney, TX 75071 RE: Acceptance Letter Project Name: Tradition Phase 4C Project Type: Storm Drain City Project No.: 103628 To Whom It May Concern: On June 7, 2024 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 July 5, 2024. 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 July 5, 2024, 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- 392-2373. Sincerely, Arash Emami Saleh, Project Manager Cc: Joey Silva , Inspector Mike Glover, Inspection Supervisor Randy Horton , Senior Inspector Andrew Goodman, Program Manager Goodwin and Marshall, Consultant PCI Construction, Contractor Hines, Developer File E-Mail: TPW_Acceptance@fortworthtexas.gov Rev. 8/20/19 AFFIDAVIT STATE OF Texas COUNTY OF Collin Before me, the undersigned authority, a notary public in the state and county aforesaid, on this day personally appeared Eric M. Lindberg, VP of Finance Of PCI Construction, Inc., 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; Water, Sanitary Sewer, Storm Drainage - Tradition Phase 4C - CPN 103628 IPRC NO. 21-0109 f f� BY Eric M. Lindberg - VP of Finance Subscribed and sworn before me on this date 10 of July, 2024. Notary Public Collin County, State of Texas BREE MITC HELL Notary ' • My I D # 123944875 i{ 027 or :�*` Expires September 26, 2 CONSENT OF OWNER ❑ SURETY COMPANY ARCHITECT ❑ TO FINAL PAYMENT CONTRACTOR ❑ SURETY ❑ AIA DOCUMENT G707 OTHER Bond No. 2340221 PROJECT: Tradition Phase 4C, Ft Worth TX (name, address) TO (Owner) [ HT Hwy 114 Development, LP ] ARCHITECT'S PROJECT NO: c/o Hines Interests 2200 Ross Ave #4200W CONTRACT FOR: Dallas, TX 75201 [ ] CONTRACT DATE: CONTRACTOR: PCI Construction, Inc. P.O. Box 2967 McKinney, TX 75070 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) Swiss Re Corporate Solutions America Insurance Corporation 1200 Main St., Suite 800 , SURETY COMPANY, on bond of (here insert name and address of Contractor) PCI Construction, Inc. P.O. Box 2967 McKinney, TX 75070 , CONTRACTOR, hereby approves of the final payment to the Contractors, 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) HT Hwy 114 Development, LP c/o Hines Interests 2200 Ross Ave #4200W ,OWNER, as set forth in the said Surety-Oompany's bond. IN WITNESS WHEREOF, the Surety Company has hereunto set its hand this 3rd day of May 2Q24 Attest: Ai (Seal): � -- Swiss Re Corporate Solutions America Insurance Surety Company Signature of Authorized Representative Debra Lee Moon Title Attornev-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 AIA DOCUMENT G707 • CONSENT OF SURETY COMPANY TO FINAL PAYMENT • APRIL 1970 EDITION • AIAO ONE PAGE © 1970 • THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 New York Ave., NW, WASHINGTON, D.C. 20006 SWISS RE CORPORATE SOLUTIONS SWISS RE CORPORATE SOLUTIONS AMERICA INSURANCE CORPORATION ("SRCSAIC") SWISS RE CORPORATE SOLUTIONS PREMIER INSURANCE CORPORATION ("SRCSPIC") WESTPORT INSURANCE CORPORATION ("WIC") GENERAL POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS, THAT SRCSAIC, a corporation duly organized and existing under laws of the State of Missouri, and having its principal office in the City of Kansas City, Missouri, and SRCSPIC, a corporation organized and existing under the laws of the State of Missouri and having its principal office in the City of Kansas City, Missouri, and WIC, organized under the laws of the State of Missouri, and having its principal office in the City of Kansas City, Missouri, each does hereby make, constitute and appoint: JOHN R. WARD, THOMAS DOUGLAS MOORE, EMILY ALLYSON MIKESKA, ALLYSON W. DEAN, MONICA RUBY VEAZEY, JOHN WILLIAM NEWBY, TROY RUSSELL KEY, DEBRA LEE MOON, ANDREA ROSE CRAWFORD, SANDRA LEE RONEY, FAITH ANN ❑IL1Y, ANDREW GARETH ADDISON, PA'TRICK 1'110MAS COYLE, MICHAEL DONALD HENDRICKSON, BRYAN KELLY MOORE, ELIZABETH ORTI%, ANA OWENS, I3£:TI-Y J RFFI L AND ANDREW PA'TRICK CLARK JOINTLY OR SEVERALLY Its true and lawful Attomey(s)-in-Fact, to make, execute, seal and deliver, for and on its behalf and as its act and deed, bonds or other writings obligatory in the nature of a bond on behalf of each of said Companies, as surety, on contracts of suretyship as are or may be required or pertnitted by law, regulation, contract or otherwise, provided that no bond or undertaking or contract or suretyship executed under this authority shall exceed the amount of: TWO HUNDRED MILLION ($200,000,000.00) DOLLARS This Power of Attorney is granted and is signed by facsimile under and by the authority of the following Resolutions adopted by the Boards of Directors of both SRCSAIC and SRCSPIC at meetings duly called and held on the 18th of November 2021 and WIC by written consent of its Executive Committee dated July 18, 2011. "RESOLVED, that any two of the President, any Managing Director, any Senior Vice President, any Vice President, the Secretary or any Assistant Secretary be, and each or any of them hereby is, authorized to execute a Power of Attorney qualifying the attorney named in the given Power of Attorney to execute on behalf of the Corporation bonds, undertakings and all contracts of surety, and that each or any of them hereby is authorized to attest to the execution of any such Power of Attorney and to attach therein the seal of the Corporation; and it is FURTHER RESOLVED, that the signature of such officers and the seal of the Corporation may be affixed to any such Power of Attorney or to any certificate relating thereto by facsimile, and any such Power of Attorney or certificate bearing such facsimile signatures or facsimile seal shall be rporation when so affixed and in the future with reeard to anv bond, undertaking or contract of surety to which it is attached." AS PR UMak ORPOR�T��2dG-' BV '• ° pa Erik Janssens, Senior Vice President of SRCSAIC &Senior Vice President s m ; S E A L - ofSRCSPIC & Senior Vice President orwic By Gerald Jn iowski, Vice President of SRCSAIC & Vice President of SRCSPIC • & & Vice President of WIC IN WITNESS WHEREOF, SRCSAIC, SRCSPIC, and WIC have caused their official seals to be hereunto affixed, and these presents to be signed by their authorized officers this llth day of January 20 24 Swiss Re Corporate Solutions America Insurance Corporation State of Illinois Swiss Re Corporate Solutions Premier Insurance Corporation County of Cook ss Westport Insurance Corporation On this 11th day of January 20 24 , before me, a Notary Public personally appeared Erik Janssens , Senior Vice President of SRCSAIC and Senior Vice President of SRCSPIC and Senior Vice President of WIC and Gerald Jaerowski , Vice President of SRCSAIC and Vice President of SPCSPIC and Vice President of WIC, personally known to me, who being by me duly sworn, acknowledged that they signed the above Power of Attorney as officers of and acknowledged said instrument to be the voluntary act and deed of their respective companies. OFFICIAL SEAL,ANiS CFiRIST1NR MCO NOTMY PUBLIC, STATE OF YldlO16 C%I("'s1ramniaftir�aGo I, Jeffrev Goldbere, the duly elected Senior Vice President and Assistant Secretary of SRCSAIC and SRCSPIC and WIC, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney given by said SRCSAIC and SRCSPIC and WIC, which is still in fill force and effect. IN WITNESS WHEREOF, I have set my hand and affixed the seals of the Companies this 3rd day of May 20 24 Jeffrey Goldberg, Senior Vice President & Assistant Secretary of SRCSAIC and SRCSPIC and WIC IMPORTANT NOTICE In order to obtain information or make a complaint You may contact Jeffrey Goldberg, Vice President - Claims, at 1-800-338-0753. You may call Swiss Re Corporate Solutions America Insurance Corporation or Swiss Re Corporate Solutions Premier Insurance Corporation's toll -free number for information or to make a complaint at: 1-800-338-0753 You may also write to Swiss Re Corporate Solutions America Insurance Corporation or Swiss Re Corporate Solutions Premier Insurance Corporation at the following address: 1450 American Lane, Suite 1100 Schaumburg, IL 60173 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: P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 475-1771 Web: htti)://www.tdi.state.tx.us E-mail: ConsumerProtectionna,tdi.state.tx. us PREMIUM OR CLAIM DISPUTES: Should you have a dispute concerning your premium or about a claim you should first contact the Swiss Re Corporate Solutions America Insurance Corporation or Swiss Re Corporate Solutions Premier Insurance Corporation. 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. AVISO IMPORTANTE Para obtener informacion o para someter un queja: Puede comunicarse con Jeffrey Goldberg, Vice President - Claims, al 1-800-338-0753. Usted puede llamr al numero de telefono gratis de Swiss Re Corporate Solutions America Insurance Corporation o Swiss Re Corporate Solutions Premier Insurance Corporation's para informacion o para someter una queja al: 1-800-338-0753 Usted tambien puede escribir a Swiss Re Corporate Solutions America Insurance Corporation o Swiss Re Corporate Solutions Premier Insurance Corporation al: 1450 American Lane, Suite 1100 Schaumburg, IL 60173 Puede escribir al Departmento de Seguros de Texas para obtener informacion acerca de companias, coberturas, derechos o quejas al: 1- 800-252-3439 Puede escribir al Departmento de Seguros de Texas: P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 475-1771 Web: httD://www.tdi.state.tx.us E-mail: Cons umerProtectionC&,,tdi.state.tx. us DISPUTAS SOBRE PRIMAS O RECLAMOS: Si time una disputa concerniente a su prima o a un reclamo, debe comunicarse con el Swiss Re Corporate Solutions America Insurance Corporation o Swiss Re Corporate Solutions Premier Insurance Corporation primero. Si no se resuelve la disputa, puede entonces comunicarse con el Departmento de Seguros de Texas. UNA ESTE AVISO A SU POLIZA: Este aviso cs solo para proposito de infromacion y no se converte en parte o condicion del documento adjunto.