HomeMy WebLinkAboutContract 60707-FP2FORT WORTHa
-FP2
City Secretary
Contract No. 60707
Date Received 10/03/2024
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: Frye Road Industrial
City Project No.: 105219
Improvement Type(s): Water x❑ Sewer ❑x
Original Contract Price:
$60,995.70
Amount of Approved Change Order(s):
$24,175.80
Revised Contract Amount:
$85,171.50
Total Cost of Work Complete:
$85,171.50
Ekent Siwlwwol2T
Brent Simmons (Oct 3. 202415:12 CDT)
Contractor
Project Manager
Title
Rockport Construction Group
Company Name
Carlos (fafccla (Oct 3, 202415:23 CDT)
Project Inspector
#1011-1—
Project Manager
Rebecca Owen (Oct 3. 202416:04 CDT)
CFA Manager
_ P
Lauren Prieur (Oct 3, 202416:15 CDT)
TPW Director
Asst. City Manager
Oct 3, 2024
Date
Oct 3, 2024
Date
Oct 3, 2024
Date
Oct 3, 2024
Date
Oct 3, 2024
Date
Oct 7, 2024
Date
OFFICIAL RECORD
CITY SECRETARY Page 1 of 2
FT. WORTH, TX
Notice of Project Completion
Project Name: Frye Road Industrial
City Project No.: 105219
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 L
Statement of Contract Time
Contract Time: 45 WD Days Charged: 76 WD
Work Start Date: 3/6/2024 Work Complete Date: 7/12/2024
Completed number of Soil Lab Test: 52
Completed number of Water Test: 2
Page 2of2
FoRTWORTH
CITY OF FORT WORTH
FINAL PAYMENT REQUEST
Contract Name FRYE ROAD INDUSTRIAL,
Contract Limits
Project Type WATER & SEWER
City Project Numbers 105219
DOE Number 5219
Estimate Number 1 Payment Number 1 For Period Ending 7/12/2024
WD
City Secretary Contract Number Contract Time 4WD
Contract Date Days Charged to Date 76
Project Manager NA Contract is 100.00 Complete
Contractor ROCKPORT CONSTRUCTION
1900 SOUTH 18TH AVENUE
WEST BEND, W1 53095
Inspectors G. DEYON / C. GARCIA
Friday, September 20, 2024 Page 1 of 5
City Project Numbers 105219 DOE Number 5219
Contract Name FRYE ROAD INDUSTRIAL Estimate Number 1
Contract Limits Payment Number 1
Project Type WATER & SEWER For Period Ending 7/12/2024
Project Funding
UNIT I: WATER IMPROVEMENTS
Item
Description of Items
Estimated Unit
Unit Cost
Estimated
Completed
Completed
No.
Quanity
Total
Quanity
Total
1
CONNECTION TO EXISTING 4-12 WATER MAIN
1 EA
$10,800.00
$10,800.00
1
$10,800.00
2
8" PVC WATER PIPE
101 LF
$68.00
$6,868.00
101
$6,868.00
3
FIRE HTDRANT
1 EA
$6,500.00
$6,500.00
1
$6,500.00
4
1" WATER SERVICE
2 EA
$3,800.00
$7,600.00
2
$7,600.00
5
8" GATE VALVE
3 EA
$2,800.00
$8,400.00
3
$8,400.00
6
4" SLD PVMY MARKING HAS (W)
57 LF
$32.38
$1,845.66
57
$1,845.66
7
24" SLD PVMY MARKING HAS (W)
48 LF
$32.38
$1,554.24
48
$1,554.24
8
SALVAGE 2" WATER METER
1 EA
$5,400.00
$5,400.00
1
$5,400.00
9
WATER LINE GROUTING
0.14 CY
$1,000.00
$140.00
0.14
$140.00
10
3" WATER ABANDONMENT PLUG
2 EA
$398.00
$796.00
2
$796.00
11
REMOVE CONC PVMT
103 SY
$10.50
$1,081.50
103
$1,081.50
12
7"CONCPVMT
103 SY
$10.50
$1,081.50
103
$1,081.50
13
TRAFFIC CONTROL
1 MO
$5,200.00
$5,200.00
1
$5,200.00
14
DUCTILE IRON FITTINGS W/ RESTRAINT
0.28 TN
$410.00
$114.80
0.28
$114.80
15
TRENCH SAFETY
132 LF
$2.00
$264.00
132
$264.00
Sub -Total of Previous Unit $57,645.70 $57,645.70
-------------
UNIT III: SEWER IMPROVEMENTS
Item
Description of Items
Estimated Unit
Unit Cost
Estimated
Completed
Completed
No.
Quanity
Total
Quanity
Total
1
MANHOLE ADJUSTMENT, MINOR
1 EA
$1,600.00
$1,600.00
1
$1,600.00
2
6" SEWER PIPE
3 LF
$48.00
$144.00
3
$144.00
3
TRENCH SAFETY (CO#1)
16 LF
$2.00
$32.00
16
$32.00
4
MANHOLE VACUUM TESTING
1 EA
$1,000.00
$1,000.00
1
$1,000.00
5
POST - CCTV INSPECTION
3 LF
$200.00
$600.00
3
$600.00
6
REMOVE 6" SEWER LINE (CO#1)
13 LF
$68.00
$884.00
13
$884.00
7
6" SEWER ABANDONMENT PLUG (CO#1)
1 EA
$380.00
$380.00
1
$380.00
8
REMOVE 4' SEWER MANHOLE (CO#1)
1 EA
$9,752.90
$9,752.90
1
$9,752.90
9
4' MANHOLE (CO#1)
1 EA
$9,752.90
$9,752.90
1
$9,752.90
10
TRAFFIC CONTROL (CO#1)
0.65 MO
$5,200.00
$3,380.00
0.65
$3,380.00
Friday, September 20, 2024 Page 2 of 5
City Project Numbers 105219 DOE Number 5219
Contract Name FRYE ROAD INDUSTRIAL Estimate Number 1
Contract Limits Payment Number 1
Project Type WATER & SEWER For Period Ending 7/12/2024
Project Funding
Sub -Total of Previous Unit $27,525.80 $27,525.80
Friday, September 20, 2024 Page 3 of 5
City Project Numbers 105219
Contract Name FRYE ROAD INDUSTRIAL
Contract Limits
Project Type WATER & SEWER
Project Funding
Contract Information Summary
Original Contract Amount
Change Orders
Change Order Number 1
Change Order Number 2
Total Contract Price
DOE Number 5219
Estimate Number 1
Payment Number 1
For Period Ending 7/12/2024
$60,995.70
$1,290.00
$22,885.80
$85,171.50
Total Cost of Work Completed $85,171.50
Less % Retained $0.00
Net Earned $85,171.50
Earned This Period $85,171.50
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
$85,171.50
Friday, September 20, 2024 Page 4 of 5
City Project Numbers 105219
Contract Name FRYE ROAD INDUSTRIAL
Contract Limits
Project Type WATER & SEWER
Project Funding
Project Manager NA
Inspectors G. DEYON / C. GARCIA
Contractor ROCKPORT CONSTRUCTION
1900 SOUTH 18TH AVENUE
WEST BEND, WI 53095
DOE Number 5219
Estimate Number 1
Payment Number 1
For Period Ending 7/12/2024
City Secretary Contract Number
Contract Date
Contract Time 45 WD
Days Charged to Date 76 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 $85,171.50
Less % Retained $0.00
Net Earned $85,171.50
Earned This Period $85,171.50
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
$85,171.50
Friday, September 20, 2024 Page 5 of 5
DocuSign Envelope ID: 3653F39F-56CF40BF-SF5B-BD9809CC1115
(PROJECT NAME:
CONTRACT:
ICFA #
CITY PROJECT #
IDOE #
WATER PROJECT #
SEWER PROJECT #
FILE #
INSPECTOR:
PROJECT MANAGER
IORIGINAL CONTRACT
IEXTRAS TO DATE
ICREDITS TO DATE
ICONTRACT TO DATE
(AMOUNT OF PROP. CHANGE ORDER
IREVISED CONTRACT AMOUNT
TOTAL REVISED CONTRACT AMOUNT
PER UNIT
REVISED COST SHARE
TOTAL REVISED CONTRACT
DEVELOPER -AWARDED -PROJECT CHANGE ORDER
WATER, SEWER AND STREET LIGHTING TO SERVE FRYE ROAD INDUSTRIAL
SEWER
CFA23-0163 I CITY PARTICIPATION: No
105219
N/A
N/A
N/A
K-3217
Phone No:
SANDIP ADHIKARI Phone No: (817) 392-8424
REVIEWED
By Sandip Adhikari at 10:42 am, Jan 16, 2024
CHANGE
ORDER No:
1
CONTRACT UNIT
WATER SEWER PAVING DRAINAGE STREET LIGHTS
Developer Developer
Cost City Cost Cost City Cost Developer Cost
$57,645.70 1 $0.00 $3,350.00 $0.00 $0.00
$57,645.70
$0.00 $3,350.00 $0.00 $0.00
$ 1,290.00
$57,645.70 1 $0.00 $4,640.00 $0.00 $0.00
Developer
City Cost
Developer Cost
City Cost
Cost
City Cost
$0.00
$0.00
$0.00
$4,015.00
$0.00
$0.00
$0.00
$0.00
$4,015.00
$0.00
$0.00
$0.00
$0.00
$4,015.00
$0.00
$57,645.70 $4,640.00 $0.00 $0.00 $4,015.00
Dev. Cost: $66,300.70 City Cost:
$66, 300.70
CONTRACT DAYS
45
45
45
Revised: 10-12-2011 Page 1
DocuSign EnvelopeIl 3653F39F56CF-40BF-8F5B-BD9809CC1115
You are directed to make the following changes in the contract documents
UNIT II: SEWER IMPROVEMENTS
CITY BID ITEM
PAY ITEM #
#
QUANTITY
3
3305.0109
13
6*
241.2012
13
7*
241.2102
1
*New Pay Item Added
REASONS FOR CHANGE ORDER
Existing 6" sewer tap removaL
RECOMMENDED:
Kimle -Horn and Associates, Inc.
By:
Name: Jeffrey Landon
Title: Project Engineer
UNIT
ITEM DESCRIPTION
UNIT PRICE
TOTAL
LF
Trench Safety
$ 2.00
$
26.00
LF
Remove 6" Sewer Line
$ 68.00
$
884.00
EA
6" Sewer Abandonment Plug
$ 380.00
$
380.00
TOTAL
$
1,290.00
APPROVED:
OBS Orlando, LLC
By: l K"". E4wu 16.1
Name: Randall Blumenthal
APPROVED:
Rockport
tCConstruction Group
By: l
Name: Brent Simmons
Title: Authorized Signatory Title: Proiect Manager
REVIEWED
By Sandip Adhikari at 10:42 am, Jan 16, 2024
Revised: 10-12-2011 Page 2
PROJECT NAME:
CONTRACT:
CFA #
CITY PROJECT#
DOE #
WATER PROJECT #
SEWER PROJECT#
FILE #
INSPECTOR:
PROJECT MANAGER:
ORIGINAL CONTRACT
EXTRAS TO DATE
CREDITS TO DATE
CONTRACT TO DATE
AMOUNT OF PROP. CHANGE ORDER
REVISED CONTRACT AMOUNT
TOTAL REVISED CONTRACT AMOUNT
PER UNIT
REVISED COST SHARE
TOTAL REVISED CONTRACT
DEVELOPER -AWARDED -PROJECT CHANGE ORDER
WATER, SEWER AND STREET LIGHTING TO SERVE FRYE ROAD INDUSTRIAL CHANGE
SEWER ORDER No:
CFA23-0163 CITY PARTICIPATION:' No
105219
NIA 2
NIA
N/A
K-3217
Carlos Garcia Phone No:
SANDIP ADHIKARI Phone No:
WATER SEWER
Developer Developer
Cost City Cost Cost City Cost Developer Cost
$57,645.70 $0.00 $3,350.00 $0.00 $0.00
$1,290.00
$57,645.70 $0.00 $4,640.00 $0.00 $0.00
$57,845,70 $0.00
$57,645.70
Dev. Cost:
S 22,885.80
$27.625.80 $0.00
$27, 525.80
$89,186.50
817-925-4381
(817)392-8424
CONTRACT UNIT
PAVING DRAINAGE STREET LIGHTS
CONTRACT DAYS
Developer
City Cost Developer Cost City Coat Cost City Cos
$0.00 $0.00 $0,00 $4,015.00 $0.00 45
Mond
$0.00 $0.00 $0.00 $4,015.00 $0.00 45
$0.00 $0.00 $0.00 $0.00 $4,015.00 $0.00 45
$0,00 ` $0.00 $4,015.00
City Cost $0.00
$89,186.50
REVIEWED
By Sandip Adhikari at 8:56 am, Sep 30, 2024
Revised: 10-12-2011 Page 1
You are directed to make the following changes in the contract documents,
CITY BID ITEM
PAY ITEM #
# QUANTITY UNIT
ITEM 4EJCRIPr ON
UNIT PRICE
TOTAL
8'
241.2201 1 EA
Remove 4 ewer anhole
$ 9,752.90
$
952.80
9'
3339.1001 1 EA
4' Manhole
$ 9,752.90
$
N2.90
10'
3471.0001 0,65 MO
Traffic Control
$ 5,200.00
$
3.380.00
TOTAL
$
22.885.80
New Pay Items Added
REASONS FOR CHANGE ORDER
Existing 4'servermanhole to be remove and replace
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:
Kimley-Horn and Associates. Inc
By: Al
Name: Jeffrey Landon
Title: Project Engineer
APPROVED:
APPROVED:
OBS do. LLLC Rockport C struction Group
By: By:� +1�
Name: Randall Blumenthal Name: Brent Simmons
Title: Authorized Signatory Title: Project Manager
REVIEWED
By Sandip Adhikari at 8:56 am, Sep 30, 2024
Revised: 10-12-2011 Page 2
FORT WORTH,
TRANSPORTATION AND PUBLIC WORKS
PIPE REPORT FOR:
PROJECT NAME: Frye Road Industril
CITY PROJECT NUMBER: 105219
1 WATER
PIPE LAID SIZE TYPE OF PIPE
C900 8 PVC
FIRE HYDRANTS: 1 VALVES (16" OR LARGER)
PIPE ABANDONED SIZE TYPE OF PIPE
DENSITIES:
NEW SERVICES:
I SEWER
PIPE LAID SIZE TYPE OF PIPE
SDR26 6 PVC
PIPE ABANDONED SIZE TYPE OF PIPE
DENSITIES:
NEW SERVICES:
TRANSPORTATION AND PUBLIC WORKS
The City of Fort Worth • 1000 Throckmorton Street • Fort Worth, TX 76012-6311
(817) 392 - 7941 • Fax: (817) 392 - 7845
LF
LF
LF
LF
101
3
FORTWORTH.
M,
TRANSPORTATION AND PUBLIC WORKS
July 12, 2024
Rockport Construction Group
8400 Belleview Drive Suite 140
Plano, TX 75024
RE: Acceptance Letter
Project Name: Frye Road Industrial
Project Type: Water, Sewer, Street Lighting
City Project No.: 105219
To Whom It May Concern:
On July 12, 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 August 30, 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 August 30, 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 Sandip
Adhikari 817-392-8424.
Sandip Adhikari, Project Manager
Cc: Carlos Garcia, Inspector
Gary Deyon, Inspection Supervisor
Lorrie Pitts, Senior Inspector
Andrew Goodman, Program Manager
Kimley Horn, Consultant
Rockport Construction Group, Contractor
Orlando Bathing Suit LLC, Developer
File
E-Mail: TPW_Acceptance@fortworthtexas.gov
Rev. 8/20/19
BILLS PAID AFFIDAVIT FOR CONTRACTOR
State of Texas §
County of Rockwall §
BEFORE ME, the undersigned authority, on this day personally appeared Yuri Ibarra known to.
me to be a credible person and officer of Ibarra Underground LLC and who, being duly sworn,
upon his oath declares and acknowledges as follows:
1. I am a duly authorized agent of Ibarra Underground LLC , which has authorized me to
make this affidavit, and all of the recitations herein are true and correct.
2. Pursuant to Private Development Contract No. 14174166 between Rockport
Construction Group and Ibarra Underaround LLC for Everything But Water, Ibarra
Underground LLC has supplied materials and performed labor in connection with the
construction of improvements on real property owned by Orlando Bathing Suit LLC in the
City of Fort Worth.
3. Ibarra Underground LLC has actual knowledge that all bills owed by Rockport
Construction Group to Ibarra Underground LLC for materials supplied or labor performed
in connection with the improvements have been fully paid and satisfied.
4. Ibarra Underground LLC has actual knowledge that all bills owed by Ibarra
Underground LLC to others for materials supplied or labor performed in connection
with the improvements have been fully paid and satisfied.
5. Ibarra Underground LLC has actual knowledge that there are no claims or liens for
materials supplied or labor performed in connection with the Private Development
Contract.
6. Ibarra Underground LLC further warrants that should any claim or lien be filed for
material supplied or labor performed in connection with the Private Development
Contract, Ibarra Underground LLC will immediately furnish a bond pursuant to Texas
Property Code Sections 53.236 through 53.238 for release of each the claim or lien,
obtain settlement of any claim or lien, and furnish the City of Fort Worth written full
release. Ibarra Underground LLC agrees to fully indemnify and hold harmless the City of
fort Worth from any and all costs that may occur by reason of such claims or liens.
EXECUTED this _r)"� day of hl kt^��ri.t 20V
I a Underarou//ndyy��LL
NA � YU ►'� ��"ma
TITLE: fi�lG�",o e✓
STATE OF TEXAS
COUNTY OF DALLAS
This instrument was acknowledged before me on-(rITI�o e r by
v r-�o.v►Y�- Pair % c.-c of Z�nerro. �L
(, L(" corporation, on behalf of saiV corporation.
[NOTARY PUBLIC STAMP] NOTARY4BLIC
MA Eli3ARRA
'! My Notary lu # 13119740E
,rr f,`�.4�,_
.E, Expires July 6, 2025
d --
CONSENT OF
SURETY COMPANY
TO FINAL PAYMENT
Owner
❑
Architect
❑
Contractor
❑
S urety
❑
Other
❑
Project: Water, Sanitary Sewer and Lighting Improvements to Serve Frye Road Industrial
(name, address) 15250 Frye Road, Fort Worth, TX 76155
TO (Owner) —1
OSA Orlando, LLC Applicable Bond Piumher:2297342
Contract For: Construction
and
City of Fort Worth, Texas
L J
Contract Date: September 20, 2023
Contractor: Ibarra Underground, LLC, 120 Nicole Drive, Rockwall, TX 78032
In accordance with the provisions of the Contract between the Owner and the Contractor as
indicated above, the
West Bend Insurance Company
1900 South 18th Avenue, West Bend, WI 53095
Surety Company, On bond of
Ibarra Underground, LLC
120 Nicole Drive, Rockwall, TX 75032
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
OBA Orlando, LLC
and
City of Fort Worth, Texas
Owner as set forth in the said Surety Companyl bond.
IN WITNESS WHEREOF,
The Surety Company has hereunto set its hand this Ist day of October, 2024.
Attest:
(Seal):
West Bend Insurance Company
Surety Company
Sig tore of Ant ized Representative
Amber ]ones. Attornev-in-Fact
Title
rWESTBEND'
POWER OF ATTORNEY
Bond No. 2297342
Know all men by these Presents, that West Bend Insurance Company (formerly known as West Bend Mutual Insurance Company prior to 11112024), a
corporation having its principal office in the City of West Bend, Wisconsin does make, constitute and appoint,
Julie Baumberger, Amber Jones, Doreen Mack, April Penny, Darrin J Weber
lawful Adomey(s)-in-fact, to make, execute, seal and deliver for and on its behalf as surety and as its act and deed any and all bonds, undertakings
and contracts of suretyship, provided that no bond or undertaking or contract of suretyship executed under this authority shall exceed in amount the
sum of: Thirty Million Dollars ($30,000,000)
This Power of Attorney is granted and is signed and sealed by facsimile under and by the authority of the following Resolution adopted by the Board
of Directors of West Bend Insurance Company by unanimous consent resolution effective the 1m day of January 2024.
Appointment ofAttorney-In-Fact. The president or any vice president or any other officer of West Bend Insurance Company may appoint by
written certificate Attorneys -in -Fact to act on behalf of the company in the execution of and attesting of bands and undertakings and other
written obligatory Instruments of like nature. The signature of any officer authorized hereby and the corporate seal may be affixed by
facsimile to any such power of attorney or to any certificate relating therefore and any such power of attorney or certificate bearing such
facsimile signatures or facsimile seal shall be valid and binding upon the company, and any such power so executed and certified by facsimile
signatures and facsimile seal shall be valid and binding upon the company in the future with respect to any bond or undertaking or other
writing obligatory in nature to which it is attached. Any such appointment may be revoked, for cause. or without cause, by any said officer at
any time.
Any reference to West Bend Mutual Insurance Company in any Bond and all continuations thereof shall be considered a reference to West Bend
Insurance Company.
In witness whereof, West Bend Insurance Company has caused these presents to be signed by its president undersigned and its corporate seal to be
hereto duly attested by its secretary this 1st day of January 2024.
+L liY.
Attest h / 1
4
L
Christopher C. Zwygart
`m : D -_ Robert j. jacques (Jn
Secretary
eP�'trsti ..a` President
State of Wisconsin
''�.�,+r+�r�r,r+�,■.�
County of Washington
On the 1st day of January 2024, before me personally came Robert Jacques, to me known being by duly swom, did depose and say that he is the
President of West Bend Insurance Company, the corporation described in and which executed the above instrument; that he knows the seal of the
said corporation; that the seal affixed to said instrument is such corporate seal; that is was so affixed by order of the board of directors of said
corporation and that he signed his name thereto by like order. ++,,
=. 7• 'OUBLtC :,? bead Corporate Attorney
`p' r- Notary Public Washington Co_ W1
My Commission is Permanent
The undersigned, duty elected to the office stated below, now the incumbent in West Bend Insurance Company, a Wisconsin corporation authorized
to make this certificate. Do Hereby Certify that the foregoing attached Power of Attorney remains in full force effect and has not been revoked and that
the Resolution of the Board of Directors, set forth in the Power of Attorney is now in force.
Signed and sealed at West Bend, Wisconsin this 1 St day of October 2024
y,�,tilf lr 11 r 0fl/�1
.� �.SU.......
_ m _ S Christopher C. Zwygart
X Z Secretary
1900 S 18th Avenue I West Bend, WI 53095 1 Phone: (800) 236-5010 1 Fax: (877) 674-2663 1 www.lhesiIveriining.com
< WEST BEND
IMPORTANT NOTICE
To obtain information or make a complaint:
You may contact West Bend Insurance Company:
1-800-760-9250
You may also write to West Bend Insurance Company
at
Attn: Claims/Surety Department
1900 S. 18th Avenue
West Bend, WI 53095
1-800-252-3439
You may write the Texas Department of Insurance:
P. ❑. Box 149104
Austin, TX 78714-9104
Fax: (512) 490-1007
Web: www.tdi.texas.gov
E-mail: ConsumerProtectionCa7tdi.texas.gov
PREMIUM OR CLAIM DISPUTES:
Should you have a dispute concerning your premium
or about a claim you should contact the agent or the
company first. If the dispute is not resolved, you may
contact the Texas Department of Insurance.
ATTACH THIS NOTICE TO YOUR BOND:
This notice is for information only and does not
become a part or condition of the attached document.
AVISO IMPORTANTE
Para ❑btener informacion o para presentar una
queja:
Usted puede comunicarse con su West Send
Insurance Company:
1-800-760-9250
Usted tambien puede escribir a West Bend Insurance
Company at:
Attn: Claims/Surety Department
1900 S. 18th Avenue
West Bend, WI 53095
1-800-252-3439
Puede escribir al ❑epartamento de Seguros de Texas:
P. O. Box 149104
Austin, TX 78714-9104
Fax: (512) 490-1007
Web: www.td!.texas.Qov
E-mail: ConsumerProtectiona-tdi-texas .gov
DISPUTAS SOBRE PRIMAS ❑ RECLAMOS:
Si tiene una disputa concerniente a su prima o a un
reclamo, debe comunicarse con el agente ❑ is
compania primero. Si no se resuelve la d+sputa, puede
entonces comunicarse con el departamento (TDI).
UNA ESTE AVISO A SU FIANZA DE GARANTiA:
Este aviso es solo para proposito de informacion y no
se convierte en parte o condicion del documento
adjunto.
NB 1671 08 23 Page 1 of 1
1900 S 18th Avenue I West Bend, WI 53095 1 Phone: (800) 236-5010 1 Fax: (877) 674-2663 1 www.thesilverlining.corn