HomeMy WebLinkAboutContract 61742-FP4FORT WORTH® �--...... _,
-FP4
City Secretary 617 42 Contract No. _____ _
Date Received 7/24/2025
7/30/2025
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: Moiser Valley North & South
City Project No.: 105188
Improvement Type(s): � Paving □Drainage □Street Lights □Traffic Signals
vwA 'ZJ,ruA.r,n1 n' :so:s2 r2:o.rn CDl) Original Contract Price: $24,257.00 ...- cy -,-
Amount of Approved Change Order(s): -$2.00
Revised Contract Amount: $24,255.00
Total Cost of Work Complete: $24,255.00
07/23/2025
Contractor Date
Accounting Manager
Title
RPMx
Company Name
S�8� 07/23/2025
Project Inspector Date
Mosa,lqge Mohanwdeen, 'P.E. 07/24/2025
Project Manager Date
07/24/2025
CFA Manager Date �-� 07/24/2025 Lauren Prieur (Jul 24, 202510:29:40 CDT)
TPW Director Date
� 07/24/2025
Asst. City Manager Date
Page 1 of 2
Notice of Project Completion
Project Name: Moiser Valley North & South
City Project No.: 105188
City's Attachments
Final Pay Estimate 0
Change Order(s): 0 Yes ❑ N/A
Contractor's Attachments
Affidavit of Bills Paid �
Consent of Surety �
Statement of Contract Time
Contract Time: 70 WD
Days Charged: 72 WD
Work Start Date: 7/10/2024 Work Complete Date: 5/9/2025
Completed number of Soil Lab Test: 88
Completed number of Water Test: 4
Page 2 of 2
CITY OF FORT WORTH
Contract Name MOSIER VALLEY NORTH & SOUTH
Contract Limits
Project Type PAVING
DOE Number 5188
Estimate Number 1 Payment Number 1 For Period Ending 5/9/2025
FINAL PAYMENT REQUEST
City Secretary Contract Number
72
WD
Contract Date
RPMX CONSTRUCTION
NA
5208 TENNYSON PARKWAY SUITE 130
PLANO TX 75024
M.GLOVER J.INOCENCIO
70WDContract Time
Days Charged to Date
CompleteContract is 100.00
Contractor
,
/Inspectors
Project Manager
City Project Numbers 105188
Tuesday, June 10, 2025 Page 1 of 4
Contract Name MOSIER VALLEY NORTH & SOUTH
Contract Limits
Project Type PAVING
DOE Number 5188
Estimate Number 1
Payment Number 1
For Period Ending 5/9/2025
Project Funding
City Project Numbers 105188
UNIT IV: PAVING
Item
No.Description of Items Estimated
Quanity Unit Unit Cost Estimated
Total
Completed
Quanity
Completed
Total
1 6" LIME TREATED SUBGRADE 64 SY $25.00 $1,600.00 64 $1,600.00
2 HYDRATED LIME @ 27 LBS./S.Y. (CO#1)0.86 TN $500.00 $430.00 0.86 $430.00
3 SAWCUT & REMOVE EX. CONCRETE CURB 1085 LF $5.00 $5,425.00 1085 $5,425.00
4 TRAFFIC CONTROL 1 LS $16,800.00 $16,800.00 1 $16,800.00
$24,255.00 $24,255.00Sub-Total of Previous Unit
Tuesday, June 10, 2025 Page 2 of 4
Contract Name MOSIER VALLEY NORTH & SOUTH
Contract Limits
Project Type PAVING
DOE Number 5188
Estimate Number 1
Payment Number 1
For Period Ending 5/9/2025
Project Funding
City Project Numbers 105188
Contract Information Summary
Change Orders
$24,257.00Original Contract Amount
$24,255.00Total Contract Price
$24,255.00
Less
Total Cost of Work Completed
% Retained $0.00
Net Earned $24,255.00
Plus Material on Hand Less 15%$0.00
Balance Due This Payment $24,255.00
Less Liquidated Damages
Days @ / Day
$0.00
Less Penalty
LessPavement Deficiency $0.00
$0.00
$0.00Less Previous Payment
Earned This Period
Retainage This Period
$24,255.00
$0.00
1 ($2.00)Change Order Number
Tuesday, June 10, 2025 Page 3 of 4
Contract Name MOSIER VALLEY NORTH & SOUTH
Contract Limits
Project Type PAVING
DOE Number 5188
Estimate Number 1
Payment Number 1
For Period Ending 5/9/2025
Project Funding
City Project Numbers 105188
Line Fund Account Center
Amount
Funded Gross Retainage Net
CITY OF FORT WORTH
SUMMARY OF CHARGES
$24,255.00
Less
Total Cost of Work Completed
% Retained $0.00
Net Earned $24,255.00
Plus Material on Hand Less 15%$0.00
Balance Due This Payment $24,255.00
Less Liquidated Damages
0 Days @ $0.00 / Day $0.00
Less Penalty
LessPavement Deficiency $0.00
$0.00
$0.00Less Previous Payment
Earned This Period
Retainage This Period
$24,255.00
$0.00
City Secretary Contract Number
72
WD
Contract Date
RPMX CONSTRUCTION
NA
5208 TENNYSON PARKWAY SUITE 130
PLANO TX 75024
M.GLOVER J.INOCENCIO
70
WD
Contract Time
Days Charged to Date
CompleteContract is 100.000000
Contractor
,
/Inspectors
Project Manager
Tuesday, June 10, 2025 Page 4 of 4
u�
N
O
N
M
O
G
�
�
N
h
�
�
W
�
W
�
W
�
C
�
�
�
�
�
r
O
�
�
�
a
�
�
C
M�
W
❑
Q
0
>
W
c
rn
N
7
U
O
0
W�
Z
a W �
_ �
U 0
O
2
Z
O
Q
d
U
F�-
�
a}
I--
U
�
C (p
r
3 d ll.�
O
� U o�o
06
� � �
3 �
Z � M
d m o
� o
� 41 O Q
(0 V � N V � �
� � Q � ^ � I� N
N � N M
O LL
� a U��o r�i X Y
x
F
U
�
H
Z
O
U
ljj # �
�
Z F
U a � W
� �
K O tai I_ F p# W
a U U U U u. X�
� M
M �
M N
� �
M M
� �
W W
Z Z
41 4)
C C
L L
a a
�
W
C�
Q
Z
� ¢
0 �
F ~
U U
W W
a �
� O
Z �
a
N
y
0
�
U
�
Z
O
U
n
y �j 'o, o o e o 0
= r M N H N N M �
� U
J W
H
W a o 0
W
� oo�oW
a �
y n � �
0 0 0 0 �
N a+ �+j N N {+j M ry
W M N
O U
O
0
0 0 0 0 0 0 o w
Vf. o 0 0 0 0 0
Y N M N N N N
U a�
� N
Z p�i
� O
d y N N N '
O N
V a o o � �
d � o 0 0 0
o �
� N N
) N N
N
G
H �j o 0 0 0 0 o p
? W � M N H M N N T N
U '�
H Q o ~ aG
Z U
U o b
d' � � O
r- o m
`m �'
p o 0 0 0 0 o w
a
�-% � N � N N N N
d r
d O
0 U
0 0 0 0 0 0 0
V o 0 0 0 0 0
�+ N N N N N N
� U o �
W H �
3 ;� � N
W o �o
N U o 0 o h �
`a � o o � o � n
a ao 0 o m o m w
� N M N M
W I� A h
> N M M
�
n
° o 0 0 0 0 0
U
L` N w w N w w y
a, U "+
Ny
f N
3 �'
e N a °D
N N �
N..
N V o o a p a N
p, N N N O
O vi N N n � n U
y p H N N 0
C U �
K
a
r
� Z F
� U
W �
O � Q �
Q
W � U t=ir O
O
= a � Z O W
U W U F �� U tn
Q W Q a Q V O >
Z Q ¢ � � � � N LL'
� p � O d Z N W Q
U p� r LLO �U W K F
Z � rN- � Z w� O
� 4
� ° z o > �-
O w U O Q w� O
g
~ o
m � �
> m
0
N
O.
O
N
>
C
W
c
rn
.N
�
U
O
�
�
�
�
�
r
(D
�
0
M
W
V
tD
ch
�
�
m
�
N
�
V
�
U
rn
m
�
N
M
W
Q
W
M
0
N
O
J
C
W
c
rn
N
7
U
O
�
. �
�
N
O
N
0
_
i
�
�
N
P
�
_
a�
a
�
��
_
W �
� °'
�
R
� cy
C
� m
� J
K
w
0
�
0
w
�
Z
Q
2
U
�
O
�
N
Z
�
Q
W
K
�
N
0
N
O
M
u�i
O
m
0
�
rn
N
( C
1 N
J � ��1 �
o � � U
Ur S N
U ' �
� � � a`
o �
x o �
� E a�
a >, m =
� m Z F
N
O
N
\
N
\
�
B
J �
J 4
i �
o�
�
C7
U
J
i�
�
O
�-+
f�
c
�
.N
'�
41
N
•r
L
�
t
1-�
7
Q
� �
E a�
m Z F-
� � �
�
>
A
J
)
)
)
v
�
v
�
a
a
c
�
�
U'
C
�
�
Q
S E ui
� T N �-
U Q! Z F
a`,
�
c
�
�
�
U
C
N
N
Q
S E ui
�L >. N
U 07 2 H
N
N
�
C
E
c
v
0
`v
�
�
U
v �
m E F
Z
v
�;
a �
.. - C U
' C '
O O ' N t0
U
� 41 � � O t0
� � c E �
� o o d V o
� $ U
m a � N L N
a .L.�. c � v L
� E ° o °� 3
m m m n � v
�`' �' o d
c m•� a u� m
W � C H U
� E � � y
C � � {Cp J y
'-'3mE `� '�
a� o�`o = �
c U �
o �'� d �
V m o a O
U � o � Z U
A C � d
C E C N N
c mi � w m
O
U >. c .c t
moa� r r
o ❑
�
�
O �
� �
H �
� (n U
W � �
r " �
� c .=
Q c U
�
�L N
m �
C �
N
2
W
[
N
n
E
0 U
w
o �
Z �
� U
� '
U �
W �L
R U
Gi �
m E F
z
`w �
a �
E o
� nq
U a
� m
� o
U
�
�
�
�
�
�
a
m
0
N
r
�
W
>
N
�
Paving Facilities
1 3211.0501 6" Lime Treated Subgrade 32 11 29 SY 64 $25.00 $1,600.00
2 3211.0400 Hydrated Lime @ 27 lbs./S.Y.32 11 29 TON 0.86 $500.00 $43 .00
3 9999.0002 Sawcut & Remove Ex. Concrete Curb 00 00 00 LF 1,085 $5.00 $5,425.00
4 9999.0004 Traffic Control 00 00 00 LS 1 $16,800.00 $16,800.00
Paving Subtotal $24,25 .00
Bid Summary
Paving Facilities Subtotal $24,25 .00
Total Bid $24,25 .00
This bid is submitted by the entity listed below:
Company: RPMx Construction, LLC By:
Street Address: 6500 Meyer Way #100
City, State, Zip Code: McKinney, TX 75070
Phone:Signature
Title:
Date:
Contractor agrees to complete WORK for FINAL ACCEPTANCE within working days
CONTRACT commences to run as provided in the General Conditions.
END OF SECTION
0
Unit Price Bid Value
Bidlist
Item Description Specification
Section No.
Unit of
Measure
Bid
Quantity
SECTION 00 42 43
Developer Awarded Projects - PROPOSAL FORM
Mosier Valley North & South Public Infrastructure Plans, City Project #105188
UNIT PRICE BID
Project Item Information RPMx
Juan Gutierrez
Estimating
05/08/2025
15
F�ORTWORTH��
TRANSPORTATION AND PUBLIC WORKS
May 20, 2025
RPMX
6500 Meyer Way Suite 100
McKinney, TX 75070
RE: Acceptance Letter
Project Name: Mosier Valley North & South
Project Type: Water, Sewer, Paving & Lighting
City Project No.: 105188
To Whom It May Concern:
On May 9, 2025 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 June 16, 2025. 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 June 16, 2025, 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-
392-2443.
Sincerely,
Motadage Mohar�r�deen,�E
Mosadage Mohammdeen, Project Manager
Cc: Jason Inocenio, Inspector
Mil<e Glover, Inspection Supervisor
Dainiel Roy, Senior Inspector
Andrew Goodman, Program Manager
GM Civil Engineering & Surveying, Consultant
RPMX, Contractor
Leon Capital Group, Developer
File
E-Mail: TPW_Acceptance@fortworthtexas.gov
Rev. 8/20/19
FINAL BILLS PAID AFFIDAVIT
THE STATE OF TEXAS
COUNTY OF COLLIN
BEFORE ME, the undersigned authority, personally appeared Amy Stavola (hereinafter
referred to as "Contracto�'), known to me to be a credibie person, and after being by me duly sworn, upon oath
stated and affirmed that:
"My name is Amy Stavola and I am the Accounting Supervisor of
RPM xConstruction, LLC , hereafter sometimes referred to in this affidavit as "Contracto�". Contractor's
business address is s5oo nnever way, ste �oo, McKinrsey 75070 . The undersigned Contractor has personal knowledge
of the facts stated herein and has full auihority to make the agreements in this affidavit on behalf of Contractor.
Pursuant to and in accordance with a written construction cantract between HBA DesiQn Build, LLC ,
Contractor, and LCG2i Mova. LLC , Owner, Contractor furnished materials and labor for the
construction, renovation, or repair of improvements located on or relating to project known as
Mosier Vallev Buildin4 #1 located at 11305 Mosier Vallev Road , City of Euless ,
Tarrant County, Texas. All work provided for under said written construction contract, together with
all changes and supplements thereto, has been fully completed in accordance with the terms and provisions
thereof.
Contractor has paid each of its subcontractors, laborers, suppliers and materialmen in full for all labor and materials
provided to Contractor for or in connection with the constructian, renovation, or repair of improvements on or
relating to the subject Property, or any po�tion thereof, excepting only the amounts owed for the following specified
bills to the persons identified below. Contractor war�ants and represents that the following specified bills will be
paid to Contractor by Owner/Administrator in reliance on this Final Bills Paid Affidavit:
Name of Pa ee Address Tele hane No. Amount Owed
American Concrete Truckin $486.50
Land Guard Erosion Control $1,431.55
The Or anic Rec cler $1 490.00
Other than the above specified bills owed to the above referenced persons, Contractor is not aware of any unpaid
bills, claims, demands, or causes of action by any of its subcontractors, laborers, suppliers, or materialmen for or in
connection with the furnishing of labor or materials, or both, for the construction, renovation, or repair of
improvements located on or related to the subject Property.
In consideration of the funds paid to Contractor by Owner and by Lender on behalf of Owner in reliance on this
affidavit, Contractor waives and releases all of Contractor's statutory and constitutional mechanic's lien rights
connected with the construction of the Project, conditioned on the actual payment or collection if payment is made
by check or draft.
Contractor further understand that this Final Bills Paid Affidavit is being given pursuant to and in accordance with
Sections 53.085 and 53.259 of the Texas Property Code and that the intentional, knowing, or reckless making of a
false or misleading statement in this Affidavit constitutes an offense under said Section and is a Class A
misdemeanor.
Contractor hereby indemnifies and holds harmless Owner from any and all claims, demands or causes of action,
R:1Project ManagementlPublicUob Files14750 - Mosier Va[ley Building #1, Euless TX - HBA Design Build, LLC\Bil[ings12025U4 - 4750 - Pay App 9
RET1202504 4750 Pay App 9RET All Bills Paid Affidavit.doc
and any costs, expenses, and attorney's fees incurred in connection therewith, arising from or connected with, the
statements and representations contained herein."
EXECUTED this 23rd
ATTEST: Chaaifi,�aeal�.i�ga.chaem,
Printed Name: Chasitv Jackson
THE STATE OF TEXAS
COUNTY OF Collin
RPM xConstruction, LLC
By: s� ��.�,
Printed Name. my Stavola
Title: Accountinq Superoisor
Before me, the undersigned authority, on this day personally appeared Amv Stavola , who first
being duly sworn by me to be the person whose name is subscribed to the foregoing Final Bills Paid Affidavit,
acknowledged that he/she has the authority to make this Final Bills Paid A�davit, and further acknowledged to me
that he/ she executed the same for the purpose and consideration therein expressed.
GIVEN UNDER MY HAND AND SEAL OF OFFICE, on this the 23rd day of �u�Y , 20 25 .
��
�„��' � ���� Notary Public i and for the
� Notary Pub1k, &tate of Texu State of TEXAS
�4 � �i1��c�1�.-�-Y028
y�a `� Ndtery ID 128277Q83 Printed Name: Sarah J. Eafiart
Commission Expires: 12/08I2028
day of Juiv , 2025.
R:1Projecl ManagemenNPublicUob Files14750 - Mosier Valley Building #1, Euless TX - HBA Design Build, LLC\Bi[Iings1202504 - 4750 - Pay App 9
RET5202504 4750 Pay App 9RET All Bilts Paid Affidavit.doc
CONSENT OF
SURETY COMPANY
TO FINAL PAYMENT
AIA DOCUMENT G707
ow�vi:�z ❑
nEzc� n�r�.cr o
CON"CRAC'[�OEZ ❑
S �LJ E2i: f Y ❑
o'r�i�-.�z
Bond Na. 2359045
PRO.IECT:
(nsimc, adtiress)
TO (O�vner) [
Mosicr Valley 1�Tortk► & South
City of �'ort Wortl�
200 'I'exas Street
Forf Worth, TX 7G1(}2
�
CONTRACTOR; �M xConsiruction, LLC
6�00 Mcyer Way, Suite 100
McKinney, TX 7507U
�
�
ARCF-I[TE:CT'S PROJECT NO:
CONTRACT FOR:
CONTRACT DATE:
In accordance with tl�e provisio��s of ihe Coi�tract between the Owner and ihe Contractor as indicated above, cl�e
(hcre inscrt namc �Er3d address of Surcty Compiny}
S�viss Rc Corparnte 5olutions America Insurance
Corporatiorx
1Z00 Main St., Suite S00 , SURETY COMPANY,
on bollC{ Of (k�crc iiiscrt il<inic aijd address of Cantractor}
RPM xConstructian, LLC
6500 Mcyer W�y, Suite 100
McKinncy, TX 7�070 , CONTRACTOR,
hereby approves of the final payE��ent to the Coi�tractors, and ���;rees that f inal payment tq the Contractor sElall ��ot relieve
[he SureEy Company of any of its obligations to (here inscrt namc anc9 acidress o1' (hv�icr)
City of Fort Wortl�
200 Tcxas Strect
Fort Wort��, TX 76102
�s set fortlt ii� the said Surety Company's bond.
IN WITNCSS WH�R�OF,
the Surety Company has here�mto set its kiand this 9th day o1� July
2Q25
,OWNER,
S�viss Re Cor�orate Solutions America lnsurance
Surety Company
f � �,
� �, 5�7, nat�cre of Authorired RepresentaCi�e
AEtest: � �� �
(Scal): �,} Andrea Rose Crawford Attornev-In-Fact
Title
NO']'li: I'his lonn is lo bc uscd as a eornpaninn documcn[ tu A1�1 [)(JCL)ML'N"1' G70G. CON"l�RACTOR'5 AFi=lllnVl"I� OF I'AYMIiN']' Ol� 131:E3'f'S At�1D Cf,A[UIS,
Currcnt I:ditinn
n1A [�OClJ�v1l:N"]' G707 • COySF.t�T OI� 511R�:1'Y COVINANY'1'O F'INn[. PAYMkiN'1' • �1PRIL 147U I?DI"I'](}N • n[nOO ONE f=AGI:
OO 1970 • Ck1L AMGR[CAN INSI'ITLJ�I�I: OI� ARCI IIl1�.CfS, 1735 I�i���- York Avc„ NW, W/1S131NG'fON, I).C. 20006
SWISS RE CORPORATE SOLUTIONS
SWISS RE CORPORATE SOLUTIONS AMERICA INSURANCE CORPORATION ("SRCSAIC")
SWISS RE CORPORATG SOLU7IOA15 PREMIER INSURANCG CORPORA770N ("SRCSPIC")
WESTPORT INSURANCE CORPORATION ("WIC")
GENERAL POWER OF ATTORNEY
KNOW ALL MEIV BY 'fI-IESE PRGSENTS, THAT SRCSAIC, a corporation duly organized and existing under laws of thc State of Missouri, and
having its principal officc in thc City of Kansas City, Missouri, and SRCSPIC, a corporation organized and existing under the laws of thc State of
Missouri and having its principal otiice in the Ciry of Kansas Ciry, Missouri, and WiC, organized under the laws of the State of Missouri, and having ics
principal office in the City of Kansas City, Missouri, each does hereby make, constitute and appoint:
JOHN R. WARD, TNOMAS DOUGLAS MOORE, EMILY ALI.ISON MIKESKA, ALLYSON W. DEAN, MONICA RUBY VEAZGY, JOHN WILLIAM NEWBY,
TROY RUSSELL IC�Y, DEBRA L�E M00�. ANDRrA ROSG CRAWFORD, SANDRA LEL� RONEY. FAITI I ANN IIILTY, AtvDRxW GARET'll ADDISON, PATRICK TI IOMAS COYLE.
MICIIAEL DONALD 11ENDRICKSON. BRYAN KIiLLY MOORI? EL�"LAHb711 ORTI'L. ANA OW�NS, BL'TTY 1 R1i1i11, AND ANDREW PATRICK CLARK JOINTLY OR SEVERALLY
Its true and lawful Attorney(s}in-Fact, to make, execute, seal and delivcr, for and on its behaltand as its act and decd, bonds or other writings
obligatory in the nature of a bond on behalfof cach of said Companies, as surery, on contracts of suretyship as are or may be required or permitted by
law, regulation, contract or othenvise, provided that no bond or undcrtaking or contract or sureryship cxecuted under this authority shaU exceed thc
amount oE
TWO HUNDRED MILLION ($200,000,000.00) DOLLARS
This Power of Attorncy is granted and is signcd by facsimile under and by the authority of thc following Resolutions adopted by the Boazds 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
Gxccutive Committee dated July 18, 201 I.
"RESOLVED, that any hvo of the Aresident, any Managing Director, any Senior Vice Presidenl, any Vice President, the Secretary or any Assistant
Secretary be, and each or any of them hereby is, authorized to execute a Powcr of Attorncy qualifying the attomey named in the given Power of
Attorney to execute on behalf of the Corporation bonds, undertakings and all conlracts of surety, and that cach or any of them hcreby is authorized to
attcst to Ihe cxecution of any such Powcr ol'Attorncy and to attach Iherein lhe seal of thc Corporation; and it is
FURTHGR RESOLVED, that the signaturc of such officers and the seal of the Corporation may be affixed to any such Power of Attorncy or to
any certificatc relating thercto by facsimile, and any such Power of Attorncy or certificatc bcaring such facsimile signatures or facsimilc seal shall be
bindine upon the Corporation when so af'fixed and in the future with reeard to anv bond, undertaking or contract of surety to which it is attached."
�� •`t�pNS AMER/��''.,, .•'�pNS PREbi ' , � `
.`_O -• - - - . G.-•'- '' � 1t _. _ .. F,q''•.._ . "�i,` .�. . , �.
SEAL��` ����SEAL
' , s�s � �' :�' '
�"�' •'y!sso�a�•;ba°-' '-s'�d'••.Missou,f.`•�' .°
'�.s,'.��Mn . �.�O�L. •��Si._ . �l�J
By
Erik ]uuseus, SenEor �a Praldmt otSRCSAIC 6� Seaior �ce Praidmt
of SRCSPIC & Senior Vice Prcaide�l of\V1C
By -�-��
Gerald Je;rowsld, Vice President of SRGSAIC & Vice Pwidmt of5RC5P1C
14 Viee Praidm� of WIC
IN W I7NF5S WHEREOP, SRCSAIC, SRC5PIC, and WIC have caused Ihcir offcial scals to 6e hcreunto affixcd, and thesc prescnu to lse signed by thcir
aulhori��ed officers
this � �� day of January
Statc of Illinois
County oFCook �
Swiss Re Corporatc Solutians America [nsarance Cor�oration
Swiss Re Corporate Solutions Premier [nsurance Corporation
Westport lnsurance Corporation
On this 11th d�, af January � ZO 24 , before me, a Notary Public personally appeared I:rik Jansscns , Senior Vice President ofSRCSAIC
and Scnior Vice President of SRCSPIC and Scnior Vice Presidcnt of WIC and Gerald Ja rg o� , Vicc Presidcnt oFSRCSAIC and Vice President of
SPCSPiC and Vice Presidcnt of WIC, personally known to me, who being by mc duly sworn, acknowlcdgcd that they signed the above Powcr of Attorney
as o�cers of and aclmawledged said instrumont to bc the voluntary act and deed of their respectivc companics.
�tAl SEAt,
CFFRIS1iNA'M/.WISLb
C��m�on�6�ksl��MMtWlLtlOs . Q���� .���� (y�
. i�f�1Sa'f3'�i+�No��'�
1, JetTrev Goldberg, the duly elected Senior Vicc President and Assistant Secretary of SRCSAIC and SRCSPIC and WIC, do hereby certify that the above and
foregoing is a uue and correct copy of a Power of Attorney given by said SRCSAIC and SRCSPIC and WIC, which is still in full force and effecG
IN W ITN6SS WHGREOF, I havc sct my liand and affixed Uic scals of the Companics this 9 day of ���Y 20 75 .
' /� t
i- .. -.r..,
JcfGey Goldbcrg, Scnior Vice President &
Assistant Sccmtary ofSRCSAfC and
SRCSPIC and WIC
20 24
►�1'�: :► ►1
In order to obtain information or make a complaint:
You may contact the Surety Claims Department
at 1-816-235-3702
You may cail Swiss Re Corporate Solutions
America Insurance Corporation or Swiss Re
Corporate Solutions Premier Insurance
Corporation for information or to make a complaint
at:
1-816-235-3702
You may also write to Swiss Re Corporate Solutions
America Insurance Corporation or Swiss Re
Corporate Solutions Premier Insurance
Corporatioa at the following address:
1200 Main Street, Suite 800
Kansas City, MO 64105
You may contact the Texas Department of Insuraace
to obtain information on companies, coverages, rights
or complaints at:
1- 80U-252-3439
You may write the Tegas Department of Insurance:
P.O. Boz 149104
Austin, TX 787149104
Fax: {512) 475-1771
Web: httn://www.tdi.state.tx.uc
E-mail:Cons� merPr�tecNonntdi.state.�. Ls
PRENIIUM 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
[nsurance.
ATTACH THIS NOTICE TO YOUR POLICY: This
notice is for information only and does not become a
part or condition of the attached document.
�\•/f.Yl]i�i71 : : ►
Para obtener informacion o para someter un queja:
al 1-816-235-3702.
Puede comunicarse con Surety Claims Department
Usted puede Ilamar Swiss Re Corporate Solutions
America Insurance Corgoration o Swiss Re
Corporate Solutions Premier Insurance
Corporation para informacion o para someter una
queja al:
1-816-235-3702
Usted tambien puede escribir a Swiss Re Corporate
Solutions America Insurance Corporation o Swiss
Re Corporate Solutions Premier Insurance
Corporation al:
1200 Main Street, Suite 800
Kansas City, MO 64105
Puede escribir al Departmento de Seguros de Texas
para ohtener informacion acerca de companias,
caberturas, derechos o quejas al:
1- 8Q0-2S2-3439
Puede escribir al Departmento de Seguros de Texas:
P.O. Box 149104
Austin, TX 787149104
Fas: (512) 475-1771
Web: h�ttn://vvww.tdi._ctate.tx.�c
E-mail:C�ns�merProtectionna tdi.state.bc. �c
DISPUTAS SOBRE PRIMAS O RECLAMOS: Si
tiene 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
Corgoration 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 es solo para proposito de infromacion y no se
converte en parte o condicion del documento adjunto.