Loading...
HomeMy WebLinkAboutContract 58815-FP1-FP1 City Secretary Contract No. 55815 FORT WORTH. Date Received 11/5/2024 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: 901 Commerce Street City Project No.: 101499 Improvement Type(s): Water ❑x Sewer x❑ Original Contract Price: $319,232.00 Amount of Approved Change Order(s) $154,343.81 Revised Contract Amount: $473,575.81 Total Cost of Work Com plete: $473,575.81 �'d // 7 rw Nov 5, 2024 Erik Kruon (Nod 5.2024 54 CST) Contractor Date Executive Vice President Title SLC Commercial Construction LLC Company Name Nov 5, 2024 Je Koonce (Nov 5, 2024 14:07 CST) Project Inspector Date 9 Nov 5, 2024 Project Manager Date Nov 5, 2024 Rebecca Owen(Nov 5. 202414:44 CST) CFA Manager Date Nov 5, 2024 TPW Director Date Nov 5, 2024 Asst. City Manager Date OFFICIAL RECORD CITY SECRETARY Page 1 of 2 FT. WORTH, TX Notice of Project Completion Project Name: 901 Commerce Street City Project No.: 101499 City's Attachments Final Pay Estimate ❑x Change Order(s): ❑x Yes ❑ N/A Pipe Report: © Yes ❑ N/A Contractor's Attachments Affidavit of Bills Paid; Consent of Surety Statement of Contract Time Contract Time: 60 WD Work Start Date: 7/19/2021 Completed number of Soil Lab Test: 81 Completed number of Water Test: 6 Days Charged: 324 WD Work Complete Date: 5/29/2024 Page 2of2 FORT WORTH CITY OF FORT WORTH FINAL PAYMENT REQUEST Contract Name WATER, SANITARY SEWER, PAVING & STREET LIGHT IMPROVEMENT Contract Limits Project Type WATER & SEWER City Project Numbers 101499 DOE Number 1499 Estimate Number 1 Payment Number 1 For Period Ending 5/29/2024 WD City Secretary Contract Number Contract Date Project Manager NA Contractor SLC COMMERCIAL CONSTRUCTION, LLC 3990 HILLSBORO PIKE, SUITE 400 NASHVILLE, TN 37215 Inspectors G.DEYON / J.KOONCE Contract Time 6'D Days Charged to Date 324 Contract is 100.00 Complete Friday, June 14, 2024 Page I of 5 City Project Numbers 101499 DOE Number 1499 Contract Name WATER, SANITARY SEWER, PAVING & STREET LIGHT IMPROVEME Estimate Number I Contract Limits Payment Number I Project Type WATER & SEWER For Period Ending 5/29/2024 Project Funding UNIT I: WATER IMPROVEMENTS Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total 1 CONSTRUCTION STAKING 1 LS $1,500.00 $1,500.00 1 $1,500.00 2 SALVAGE 1" WATER METER 1 EA $2,400.00 $2,400.00 1 $2,400.00 3 5' WIDE ASPHALT PVMT REPAIR, ARTERIAL 157 LF $150.00 $23,550.00 157 $23,550.00 4 DUCTILE IRON WATER FITTINGS W/ 0.25 TN $41,400.00 $10,350.00 0.25 $10,350.00 RESTRAINT 5 6" WATER PIPE, CLSM BACKFILL 10 LF $290.00 $2,900.00 10 $2,900.00 6 8" WATER PIPE, CLSM BACKFILL 49 LF $440.00 $21,560.00 49 $21,560.00 7 WATER SAMPLING STATION 4 EA $3,200.00 $12,800.00 4 $12,800.00 8 6" WATER METER AND VAULT I EA $27,800.00 $27,800.00 1 $27,800.00 9 6" GATE VALVE I EA $1,400.00 $1,400.00 1 $1,400.00 10 8" GATE VALVE 2 EA $2,100.00 $4,200.00 2 $4,200.00 11 12" CUT -IN GATE VALVE 2 EA $14,200.00 $28,400.00 2 $28,400.00 12 16" CUTOIN GATE VALVE W/VAULT 1 EA $37,200.00 $37,200.00 1 $37,200.00 13 TRAFFIC CONTROL 1 MO $2,200.00 $2,200.00 1 $2,200.00 Sub -Total of Previous Unit $176,260.00 $176,260.00 UNIT M SANITARY SEWER IMPROVEMENTS Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed No. Quanity Total Quanity Total --------------------------------------- 1 CONSTRUCTION STAKING 1 LS $1,100.00 $1,100.00 1 $1,100.00 2 REMOVE 8" SEWER LINE 74 LF $40.00 $2,960.00 74 $2,960.00 3 REMOVE 4' SEWER MANHOLE (CO#1) 0 EA $2,500.00 $0.00 0 $0.00 4 1O' WIDE ASPHALT PVMT REPAIR, ARTERIAL 36 LF $280.00 $10,080.00 36 $10,080.00 5 ASPHALT PVMT REPAIR BEYOND DEFINED 139 SY $225.00 $31,275.00 139 $31,275.00 WIDTH, ARTERIAL 6 POST -CCTV INSPECTION 79 LF $25.00 $1,975.00 79 $1,975.00 7 MANHOLE VACUUM TESTING 2 EA $220.00 $440.00 2 $440.00 8 TRENCH SAFETY 79 LF $8.00 $632.00 79 $632.00 9 CONCRETE COLLAR 3 EA $450.00 $1,350.00 3 $1,350.00 10 TRENCH WATER STOPS 2 EA $620.00 $1,240.00 2 $1,240.00 11 8" SEWER PIPE, CLSM BACKFILL 5 LF $460.00 $2,300.00 5 $2,300.00 12 12" SEWER PIPE, CLSM BACKFILL 95 LF $510.00 $48,450.00 95 $48,450.00 Friday, June 14, 2024 Page 2 of 5 City Project Numbers 101499 DOE Number 1499 Contract Name WATER, SANITARY SEWER, PAVING & STREET LIGHT IMPROVEME Estimate Number I Contract Limits Payment Number I Project Type WATER & SEWER For Period Ending 5/29/2024 Project Funding 13 EPDXY MANHOLE LINER 10 VF $220.00 $2,200.00 10 $2,200.00 14 4' MANHOLE I EA $12,000.00 $12,000.00 1 $12,000.00 15 4' EXTRA DEPTH MANHOLE 4 VF $300.00 $1,200.00 4 $1,200.00 16 5' MANHOLE (CO#1) 0 EA $17,400.00 $0.00 0 $0.00 17 5' EXTRA DEPTH MANHOLE (CO#1) 0 VF $310.00 $0.00 0 $0.00 18 TRAFFIC CONTROL I MO $2,200.00 $2,200.00 1 $2,200.00 19 12"-2-WAY CLEANOUT I EA $1,500.00 $1,500.00 1 $1,500.00 20 MANHOLE ADJUSTMENT, MAJOR W/ COVER 1 LS $19,413.81 $19,413.81 1 $19,413.81 (CO#I) 21 BYPASS PUMPING (CO #1) 1 LS $157,000.00 $157,000.00 1 $157,000.00 Sub -Total of Previous Unit $297,315.81 $297,315.81 Friday, June 14, 2024 Page 3 of 5 City Project Numbers 101499 DOE Number 1499 Contract Name WATER, SANITARY SEWER, PAVING & STREET LIGHT IMPROVEME Estimate Number I Contract Limits Payment Number I Project Type WATER & SEWER For Period Ending 5/29/2024 Project Funding Contract Information Summary Original Contract Amount $319,232.00 Change Orders Change Order Number 1 $154,343.81 Total Contract Price $473,575.81 Total Cost of Work Completed $473,575.81 Less % Retained $0.00 Net Earned $473,575.81 Earned This Period $473,575.81 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 $473,575.81 Friday, June 14, 2024 Page 4 of 5 City Project Numbers 101499 DOE Number 1499 Contract Name WATER, SANITARY SEWER, PAVING & STREET LIGHT IMPROVEME Estimate Number I Contract Limits Payment Number I Project Type WATER & SEWER For Period Ending 5/29/2024 Project Funding Project Manager NA Inspectors G.DEYON / J.KOONCE Contractor SLC COMMERCIAL CONSTRUCTION, LLC 3990 HILLSBORO PIKE, SUITE 400 NASHVILLE, TN 37215 City Secretary Contract Number Contract Date Contract Time 60 WD Days Charged to Date 324 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 $473,575.81 Less % Retained $0.00 Net Earned $473,575.81 Earned This Period $473,575.81 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 $473,575.81 Friday, June 14, 2024 Page 5 of 5 PROJECT NAME: CONTRACT: CFA # CITY PROJECT # DOE # WATER PROJECT # SEWER PROJECT # FILE # INSPECTOR: PROJECT MANAGER DEVELOPER -AWARDED -PROJECT CHANGE ORDER WATER, SANITARY SEWER, PAVING, AND STREET LIGHT IMPROVEMENTS TO SERVE 901 COMMERCE STREET CHANGE CS-55815 ORDER No: CFA19-0111 CITY PARTICIPATION: I NO 101499 NA 56008-0600430-101499-001580 56008-0700430-101499-001380 K-2753, X-26477 JEREMY KOONCE Phone No: 832.527.5406 REVIEWED DEBBIE J. W ILLHELM, PE Phone No: 817.392.2481 By Debbie J. Willhelm at 3:20 pm, May 29, 2024 WATER Cost I City Cost ORIGINAL CONTRACT $176,260.00 I $0.00 EXTRAS TO DATE $0.00 I $0.00 CREDITS TO DATE $0.00 I $0.00 CONTRACT TO DATE $176,260.00 I $0.00 AMOUNT OF PROP. CHANGE ORDER $0.00 I $0.00 REVISED CONTRACT AMOUNT $176,260.00 I $0.00 TOTAL REVISED CONTRACT AMOUNT PER UNIT $176,260.00 REVISED COST SHARE Dev. Cost: TOTAL REVISED CONTRACT CONTRACT UNIT SEWER PAVING STREET LIGHTS LANDSCAPE ;ost City Cost Cost City Cost $142,972.00 $0.00 $417,649.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142,972.00 $0.00 $417,649.56 $0.00 $ 154,343.81 $0.00 $ 3,088.46 $0.00 $297,315.81 $0.00 $420,738.02 $297,315.81 $420,738.02 $1,032,982.24 City Cost: $1, 032,982.24 leveloper Developer :ost City Cost Cost $138,668.41 I $0.00 I $71,613.36 $0.00 $0.00 I $0.00 $0.00 $0.00 I $0.00 $138,668.41 $0.00 I $71,613.36 $0.00 I $0.00 I-71,613.36 $138,668.41 $0.00 I $0.00 $138,668.41 $0.00 $0.00 ty Cost $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 WORKING DAYS 60 0 0 60 0 60 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 DESCRIPTION UNIT PRICE I TOTAL UNIT II: SANITARY SEWER IMPROVEMENTS 3 0241.2201 -1 EA REMOVE 4' SEWER MANHOLE $ 2,500.00 $ (2,500.00) 16 3339.1101 -1 EA 5' MANHOLE $ 17,400.00 $ (17,400.00) 17 3339.1103 -7 VF 5' EXTRA DEPTH MANHOLE $ 310.00 $ (2,170.00) NEW ITEM 3305.0114 1 EA MANHOLE ADJUSTMENT, MAJOR W/ COVER $ 19,413.81 $ 19,413.81 NEW ITEM 3303.0001 1 LS BYPASS PUMPING $ 157,000.00 $157,000.00 SANITARY SEWER IMPROVEMENTS SUBTOTAL $154,343.81 UNIT III: PAVING IMPROVEMENTS 9 3212.0303 5 SY 3" ASPHALT PVMT TYPE ID$ 5.42 $ 27.10 11 3213.0301 109 SF 4" CONCRETE SIDEWALK $ 10.76 $ 1,172.84 12 3213.0503 1 EA BARRIER FREE RAMP, TYPE M-1 $ 1,888.52 $ 1,888.52 � 1 2 3 4 REASONS FOR CHANGE ORDER PAVING IMPROVEMENTS SUBTOTALS $ 3,088.46 UNIT V: LANDSCAPE IMPROVEMENTS 3110.0102 -6 EA 6"-12" TREE REMOVAL $ 510.91 $ (3,065.46) 3293.0106 -16 EA PLANT 6" TREE $ 1,921.00 $ (30,736.00) 9999.0002 -2 EA SALVAGE EXISTING TRASH CAN $ 145.95 $ (291.90) 9999.0005 -16 EA 48" SQUARE TREE GRATE $ 2,345.00 $ (37,520.00) LANDSCAPE IMPROVEMENTS SUBTOTAL $ (71,613.36) GRAND TOTAL $ 85,818.91 EXISTING SSMH AT 8TH AND COMMERCE STREET WAS STRUCTURALLY SOUND; ONLY NEEDED TO REPLACE THE MANHOLE CONE, RING, & COVER. BY-PASS PUMPING LINE ITEM WAS ALSO ADDED TO FACILITATE CONSTRUCTION OF SS LINE A. CHANGES CORRESPOND TO REVISION NO. 1 AS SHOWN ON SHEETS C1.00, C1.01, C1.02 AND C1.04 OF THE CONSTRUCTION PLANS. CHANGE ORDER NEEDED TO REPLACE THE EXISTING ADA RAMP AND SURROUNDING ASPHALT PAVEMENT AT THE SOUTHEAST CORNER OF CALHOUN STREET AND EAST 8TH STREET. CHANGES CORRESPOND TO REVISION NO. 1 AS SHOWN ON SHEETS C2.00 AND C3.00 OF THE CONSTRUCTION PLANS. REMOVING LANDSCAPING ITEMS FROM THE CFA; THESE ITEMS ARE NOT CITY ASSETS. THESE ITEMS WILL BE COORDINATED AND MAINTAINED BY THE OWNER. 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: KIMLEY-HORN AND ASSOCIATES, INC 9TH AND COMMERCE FORT WORTH, LLC By: Name: Brandon Middleton Title: Civil Engineer DocuSigned by: B: Name: Title: President APPROVED: SLC COMMERCIAL CONSTRUCTION, LLC DocuSigned by: B �l 74 Name: DES K"Offop Title: EVP - commercial construction Revised: 10-12-2011 Page 2 FORTWORTH TRANSPORTATION AND PUBLIC WORKS PIPE REPORT FOR: PROJECT NAME: 901 Commerce CITY PROJECT NUMBER: 101499 WATER PIPE LAID SIZE TYPE OF PIPE LF C-900 6" PVC 10 C-900 8" PVC 49 FIRE HYDRANTS: N/A VALVES (16" OR LARGER) PIPE ABANDONED SIZE TYPE OF PIPE LF DENSITIES: Yes NEW SERVICES: 6" PVC 1 EA. 8" PVC 2 EA. SEWER PIPE LAID SIZE TYPE OF PIPE LF SDR 26 8" PVC 5 SDR 26 12" PVC 95 PIPE ABANDONED SIZE TYPE OF PIPE LF DENSITIES: Yes NEW SERVICES: 12" PVC 1 EA. 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 June 5, 2024 SLC Commercial Construction LLC 3990 Hillsboro Pike, Suite 400 Nashville, TN 37215 RE: Acceptance Letter Project Name: 901 Commerce Street Project Type: Developer City Project No.: 101499 To Whom It May Concern: On May 28, 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 May 29, 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 May 29, 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 (832)527-5406. Sincerely, T e66� � uJ�l Debbie Willhelm, Project Manager Cc: Jeremy Koonce, Inspector Lorrie Pitts, Inspection Supervisor Gary Deyon, Senior Inspector Andrew Goodman, Program Manager Kimley Horn, Consultant Southern Land Company, Contractor Southern Land Company, Developer File E-Mail: TPW_Acceptance@fortworthtexas.gov Rev. 8/20/19 SLC COMMERCIAL CONSTRUCTION, LLC 3990 Hillsboro Pike, Suite 400 Nashville, TN 37215 October 30, 2024 City of Fort Worth CFA Administration 200 Texas St. Fort Worth, TX 76102 RE: 901 Commerce (Deco 969); 969 Commerce Street, Fort Worth, TX CFA No.: CFA19-0111 City Project No.: 101499 IPRC No.: 19-0156 City Contract No.: 55815 COMPONENTS: Water, Sewer, Paving, Street Lights The purpose of this letter is to acknowledge that SLC Commercial Construction, LLC has been paid in full by 9th and Commerce Fort Worth, LLC c/o Southern Land Company for the public improvements constructed to serve 901 Commerce in Fort Worth, Texas. As a result, we hereby waive, release and relinquish all rights to assert any claim or demand for lien in connection with this project. Please feel free to contact me with any questions you may have. Sincerely, SLC COMMERCIAL CONSTRUCTION, LLC By: / Name:,t�iry�e� Title: Ppee�e t Ue Ale�J&#k Bond No. 60141361 006219-1 MAINTENANCE BOND Page 1 of 3 1 SECTION 00 62 19 2 MAINTENANCE BOND 3 4 THE STATE OF TEXAS § 5 § KNOW ALL BY THESE PRESENTS: 6 CO U NTY OF TARRANT § 7 8 That we SLC COMMERCIAL CONSTRUCTION, LLC, known as "Principal" herein and CAPITOL 9 INDEMNITY CORPORATION, a corporate surety (sureties, if more than one) duly authorized to do 10 business in the State of Texas, known as "Surety" herein (whether one or more), are held and 11 firmly bound unto the Developer, 97H AND COMMERCE FORT WORTH, LLC, authorized to do 12 business in Texas ("Developer") and the City of Fort Worth, a Texas municipal corporation 13 ("City"), in the sum of Nine Hundred Forty -Seven Thousand One Hundred Sixtv-Three and 14 33 100 DOLLARS ($947,163.33), lawful money of the United States, to be paid in Fort Worth, 15 Tarrant County, Texas, for payment of which sum well and truly be made jointly unto the 16 Developer and the City as dual obligees and their successors, we bind ourselves, our heirs, 17 executors, administrators, successors and assigns, jointly and severally, firmly by these presents. 18 WHEREAS, Developer and City have entered into an Agreement for the construction of 19 community facilities in the City of Fort Worth by and through a Community Facilities Agreement, 20 CFA Number CFA19-0111; and 21 WHEREAS, the Principal has entered into a certain written contract with the Developer 22 awarded the day of . 2021, which Contract is hereby 23 referred to and a made part hereof for all purposes as if fully set forth herein, to furnish all 24 materials, equipment labor and other accessories as defined by law, in the prosecution of the 25 Work, including any Work resulting from a duly authorized Change Order (collectively herein, 26 the "Work") as provided for in said Contract and designated as WATER, SANITARY SEWER, 27 PAVING, AND STREET LIGHT IMPROVEMENTS TO SERVE 901 COMMERCE STREET, • and W CITY OF FORT WORTH IPRC29-0156 STANDARD CITY CONDITIONS — DEVELOPER AWARDED PROJECTSCITY PROJECT NO. 101499 Revised January 31, 2012 006219-2 MAINTENANCE BOND Page 2 of 3 1 WHEREAS, Principal binds itself to use such materials and to so construct the Work in 2 accordance with the plans, specifications and Contract Documents that the Work is and will 3 remain free from defects in materials or workmanship for and during the period of two (2) years 4 after the date of Final Acceptance of the Work by the City ("Maintenance Period"); and 5 WHEREAS, Principal binds itself to repair or reconstruct the Work in whole or in part upon 6 receiving notice from the Developer and/or City of the need thereof at any time within the 7 Maintenance Period. 8 NOW THEREFORE, the condition of this obligation is such that if Principal shall remedy 9 any defective Work, for which timely notice was provided by Developer or City, to a completion 10 satisfactory to the City, then this obligation shall become null and void; otherwise to remain in 11 full force and effect. 12 PROVIDED, HOWEVER, if Principal shall fail so to repair or reconstruct any timely 13 noticed defective Work, it is agreed that the Developer or City may cause any and all such 14 defective Work to be repaired and/or reconstructed with all associated costs thereof being 15 borne by the Principal and the Surety under this Maintenance Bond; and 16 PROVIDED FURTHER, that if any legal action be filed on this Bond, venue shall lie in 17 Tarrant County, Texas or the United States District Court for the Northern District of Texas, Fort 18 Worth Division; and 19 PROVIDED FURTHER, that this obligation shall be continuous in nature and successive 20 recoveries may be had hereon for successive breaches. 21 CITY OF FORT WORTH JPRC19-0I56 STANDARD CITY CONDITIONS — DEVELOPER AWARDED PROJECTSCITY PROJECT NO. 101499 Revised January 31, 2012 1 2 3 4 5 6 7 8 9 10 1.1 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 006219-3 MAINTENANCE BOND Page 3 of 3 IN WITNESS WHEREOF, the Principal and the Surety have each SIGNED and SEALED this instrument by duly authorized agents and officers on this the 29th day of April, 2021. ATTEST: (Principaf� Secretary 1¢I4F_X f; sC�. Witness as to PKcipal ATTEST: (Surety)�Tvltness Witness as to S etv PRINCIPAL: SLC COM RICA4�O IN, LLC BY: Signatur C Name and britle (/ Address: 3990 Hillsboro Pike, Suite 400 Nashville, TN 37125 SURETY: CAPITOL MNITY CORAL) TION BY: Si ture Phyllis T. Neal, Attorney -in -Fact Name and Title Address: 1600Aspen Commons, Suite 300 Middleton, WI 53562 Telephone Number: 800-475-4450 37 *Note: If signed b an officer of the Surety Company, there must be on file a certified extract 38 from the by- s showing that this person has authority to sign such obligation. If 39 Surety's physical address is different from its mailing address, both must be provided. CITY OF FORT WORTH 1PRC19-0156 STANDARD CITY CONDITIONS —DEVELOPER AWARDED PROJECTSCITY PROJECT NO. 101499 Revised January 31, 2012 3 006219-4 MAINTENANCE BOND Page 4 of 3 The date of the bond shall not be prior to the date the Contract is awarded. CITY OF FORT WORTH IPRC19-0156 STANDARD CITY CONDITIONS — DEVELOPER AWARDED PROJ ECTSC[TY PROJECT NO. 101499 Revised January 31, 2012 CAPITOL INDEMNITY CORPORATION 60141361 POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS. That the CAPITOL INDEMNITY CORPORATION, a atritaraticm of the .Sl:i<< of Wi:;cun,i t. ha ilt� its principal offices in the City of Middleton. Wisconsin. does make. constitute and appoint --------------------ROBERT E. G IGAX, JR.; SHELLY M. MARTIN; PHYLLIS T. NEAL its Inje and lawful Attomey(s)Ari-fact, to make, execute, seal and deliver 'fatr aud:on its behall , as surety, and as is act and deed, any and all honds, undertakings and contracts of suretyship. provided that no bond or undertaking Or conglact of suretyship executed under this authority shall exceed in arnnunt the sum (ai ----------------------------AI.L WRITTEN INSTRUMENTS IN AN AMOUNT NOT TO EXCEED:$20,000,000.00------- ------- —--------- --- This Power of Attorney is �ranlcd and is signed and sealed by facsnni}e under and by the cuthority of the following Rcsohnion adopted bN the B,)ard of Directors of CAPITOL INDEMNITY CORPORATION at a meeting duly called and held on the 8th day of Linuary, 20.02. "RESOLVED, that the President, Executive Vice President, Vice President, See:rc:nsry or Treasurer. acting individually or niberwise. be and they hereby t„ are granted the power and authorization to appoint by a Power of Attorneyfor the purposes only of executing and attesting=..bonds sand undca'takings, and _ usher writings obligatory in the nature thereof, one or more resident vice-presidents, :assistant secretaries and altorrtcy(s)-in-fact, each, appointee to have the powers and duties usual to such oft -ices to the business of this company: the signature cif such officers and seal of the Company may be affixed to auy such power of attorney or to any certificate relating thereto by facsimile, and any such power Of attorney or certificate hearing such facsimile signatures or facsimile seal shall be valid and binding upon the Company, and any such power so executed and testified by facsimile signatures and facsimile Neal shall be valid and binding upon the Company in the future with respect to any bond or undertaking Or Other writing obligatory in the nature thoreuf to - which it is attached. Any such appointment may be revoked, for cause, or without cause, by any of said officers, at any time.'' In connection with obligations in favor of the Florida Department of Transporration only. it is agreed that the power and authority hereby given In the Attorney -in -Fact includes any and all consents for the release of retained percentages'aind/or final estimates on engineering, and construction cOntrack _ 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 leant thirty (30) day -prior to the modification or revocation. IN WITNESS WHEREOF. the CAPITOL. INDEMNITY CORPORATION has caused these presents to be signed by its officer undersigned and its corporate seal to be hereto affixed duly attested, this 3rd day of May,'2011. er Atwst: 1��, � /1; C'AP[TOL INDEMNITY CORPORATION CORPORATION _ Q�o4 GORP�FUITp n'?) ry I/ ` / •� John E. Rzepinski `� - • -- ,:a __ � =�� Vice President, Treasurer & CFO r SEA L _ Stephen 1. `:ills l CEO &'President :» - r� l`t Suzanne M. Broadbent Assistant Secretary STATi~ OF WISCONSIN COUNTY OF DANE 5.5.: On the 3rd day of May, 2017 before me personally came Stephen J. Sills, to me known, who being by me duly sworn, did depose and say: that he rc:,tdCs in the County of New York, State of New York; that he is President of CAPITOL INDEMNITY CORPORATION, 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 it was so affixed by order of the Board of Directors of said corporation and that he signed his name thereto by like order. kt.tn Z David .I. Rc,el'e STATE OF W[SCONSIN 1 s Notary Public. Dane Co., Wi COUNTY OF DANE r k �,,, My Commission Is Permanent I, the undersigned, duly elected to the office stated below. now the incumbent in CAPITOL INDEMNITY CORPORATION. a Wisconsin Corporation. authorized to make this ctrtifAcate, DO HEREBY CERTIFY that the fureeoing sttached. Power of Attorney remains in full force and has not been revoked; :and furthermore, that the Resolution of the Board of Directors, set forth in the Power of Attorney is now in force. Signed and sealed at the City of Middleton. State of Wisconsin this 29th day of � , 20 71 WA Antonio Celii General Counsel, Vice President & Secretary THIS DOCUMENT IS NOT VALID UNLESS PRiNTED ON GRAY SHADED BACKQ1ZQ1.1N13 WITH A RED SERIAL NUMBER iN THE- tit"PER RIGHT HAND CORNER IF YOU HAVE. ANY QUESTIONS CONCERNING THE All -iENT1CITY OF THIS DOCUMENT CALL800-475-41j0. CIC-POA tR,,. 10.2017 CAPITOL INDEMNITY CORPORATION BALANCE SHEET December 31, 2020 Admitted Assets Cash and invested assets: Bonds $ 540,050,945 Common stocks 136,823,713 Cash, cash equivalents and short-term investments 51,386,666 Other invested assets 74,185 Receivables for securities 7,139 Total cash and invested assets 728,342,648 Investment income due and accrued 3,025,223 Uncollected premiums and agents' balances in course of collection 43,072,989 Deferred premiums, agents' balances and installments booked but deferred and not yet due 9,868,137 Amounts recoverable from reinsurers 5,847,405 Other amounts receivable under reinsurance contracts 97,063 Current federal and foreign income tax recoverable and interest thereon 363,716 Net deferred tax asset 15,146,078 Electronic data processing equipment and software 1,890,377 Receivables from parent, subsidiaries and affiliates 39,560 Total admitted assets $ 807,693,196 Liabilities and Surplus as Regards Policyholders Liabilities: Losses $ 275,220,050 Reinsurance payable on paid losses and loss adjustment expenses 17,552,032 Loss adjustment expenses 54,378,410 Commissions payable, contingent commissions and other similar charges 434,788 Other expenses f excluding taxes, licenses and fees) 8,988,870 Taxes, licenses and fees (excluding federal and foreign income taxes) 580,794 Unearned premiums 136,642,443 Advance Premium 5,481 Ceded reinsurance premiums payable (net of ceding commissions) 4,835,724 Amounts withheld or retained by company for account of others 11,806,760 Provision for reinsurance 208,000 Payable to parent, subsidiaries and affiliates 16,308,674 Payable for securities 313 Other liabilities 561,483 Total liabilities 527,523,822 Surplus as regards policyholders: Common capital stock 4,201,416 Gross paid in and contributed surplus 103,923,753 unassigned funds (surplus) 172,044,205 Surplus as regards policyholders 280,169,374 Total liabilities and capital and surplus $ 807,693,196 I, John L. Sennott Jr., CEO and President of Capital Indemnity Corporation do hereby certify that to the best of my knowledge and belief, the foregoing is a full and true statutory Statement of Admitted Assets and Liabilities, Capital and Surplus of the Operation at December 31, 2020, prepared in conformity with the accounting practices prescribed by the Insurance Department of the State of Wisconsin. IN WITNESS WHEREOF, I have set my hand and affixed the seal of the Corporation at Middleton, Wisconsin. C�V-� Ls4 John L. Sennott Jr CEO & President 0.0 J+ S JFr�� • ° ipb4ETDN aV Capitol Indemnity Corporation 1600 Aspen Commons, Middleton, W153562 IMPORTANT NOTICE - TEXAS To obtain information or make a complaint: • You may contact your company representative at 1-800-475-4450 • You may call Capitol Indemnity Corporation's toll -free telephone number for information or to make a complaint at: 1-800-475-4450 • You may also write to Capitol Indemnity Corporation at: Capitol Indemnity Corporation 1600 Aspen Commons Middleton, Wisconsin 53562 • 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) 490-1007 Web: httr)://www.tdi.texas.aov E-mail: Con sumerProtection aetdi.texas. aov • 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 POLICY: This notice is for information only and does not become a part or condition of the attached document. SGE 020 (06-16) O 2016 CapSpecialty, Inc. All rights reserved. Page 1 of 1