HomeMy WebLinkAboutContract 61645-FP4-FP4
FORT WORTH,
City Secretary,
Contract No.
Date Received 7/31/2025
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: Branding Iron Townhomes
City Project No.: 104198
Improvement Type(s): Water ❑x Sewer ❑x
Original Contract Price: $844,562.30
Amount of Approved Change Order(s):-$326.00
Revised Contract Amount: $844,236.30
Total Cost of Work Complete: $844,236.30
Gbet-t 61-a4 7es 07/28/2025
A11-1 Gi"'c—'],,I)" 202, 11c 30 CDTI
Contractor Date
Vice President
Title
Burnsco Construction, Inc
Company Name
07/28/2025
Mk el lns(Ju128, 202511:52:54 CDT)
Project Inspector
Date
07/30/2025
Project Manager
Date
07/31/2025
CFA Manager
Date
X.Fll
07/31/2025
Lauren Pi ieur (Jul 31, 2025 13:36:49 CDT)
TPW Director
Date
07/31/2025
Asst. City Manager Date
OFFICIAL RECORD Page 1 of 2
CITY SECRETARY
FT. WORTH, TX
Notice of Project Completion
Project Name: Branding Iron Townhomes
City Project No.: 104198
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
r
Statement of Contract Time
Contract Time: 115
Days Charged: 134
Work Start Date: 11/4/2024 Work Complete Date: 7/18/2025
Completed number of Soil Lab Test: 408
Completed number of Water Test: 7
Page 2 of 2
FORT WORT 11
CITY OF FORT WORTH
FINAL PAYMENT REQUEST
Contract Name BRANDING IRON TOWNHOMES
Contract Limits
Project Type WATER & SEWER
City Project Numbers 104198
DOE Number 4198
Estimate Number 1 Payment Number 1 For Period Ending 7/18/2025
WD
City Secretary Contract Number Contract Time I IVYD
Contract Date Days Charged to Date 134
Project Manager NA Contract is 100.00 Complete
Contractor BURNSCO CONSTRUCTION, INC.
6331 SOUTHWEST BLVD
FORT WORTH, TX 76132
Inspectors M.GLOVER / M.PERKINS
Monday, July 28, 2025 Page 1 of 5
City Project Numbers 104198 DOE Number 4198
Contract Name BRANDING IRON TOWNHOMES Estimate Number I
Contract Limits Payment Number 1
Project Type WATER & SEWER For Period Ending 7/18/2025
Project Funding
UNIT I: WATER EVIROVEMENTS
Item
Description of Items
Estimated Unit
Unit Cost
Estimated
Completed
Completed
No.
Quanity
Total
Quanity
Total
1
REMOVE CONC PVMT
102 SY
$15.00
$1,530.00
102
$1,530.00
2
REMOVE 4" WATER LINE
64 LF
$16.00
$1,024.00
64
$1,024.00
3
REMOVE 8" WATER LINE
64 LF
$16.00
$1,024.00
64
$1,024.00
4
4"-12" WATER ABANDAMENT PLUG
4 EA
$150.00
$600.00
4
$600.00
5
REMOVE 6" WATER VALVE
2 EA
$700.00
$1,400.00
2
$1,400.00
6
REMOVE 8" WATER VALVE
2 EA
$800.00
$1,600.00
2
$1,600.00
7
REMOVE CONCRETE WATER VAULT
1 EA
$2,500.00
$2,500.00
1
$2,500.00
8
CONC PVMT REPAIR, RESIDENTAIL
102 SY
$210.00
$21,420.00
102
$21,420.00
9
8" WATER LOWERING
4 EA
$500.00
$2,000.00
4
$2,000.00
10
TRENCH WAFETY
2643 LF
$0.10
$264.30
2643
$264.30
11
DUCTILE IRON WATER FITTINGS W/ RETRAINT
0.85
$10,200.00
$8,670.00
0.85
$8,670.00
12
8" PVC WATER PIPE
2643 LF
$58.00
W3,294.00
2643
$153,294.00
13
FIRE HYDRANT
2 EA
$8,000.00
$16,000.00
2
$16,000.00
14
CONNECTION TO EXISTING 4"-12" WATER
2 EA
$4,800.00
$9,600.00
2
$9,600.00
MAIN
15 1" WATER SERVICE (CO#1) 126 EA
16 8" GATE VALVE 11 EA
17 RE -LOCATE EXISTING FIRE HYDRANT 1 EA
18 AUTO FLUSH VALVE 1 EA
Sub -Total of Previous Unit
-------------------
UNIT II: SANITARY SEWER
$1,410.00 W7,660.00 126 $177,660.00
$2,500.00 $27,500.00 11 $27,500.00
$3,000.00 $3,000.00 1 $3,000.00
$7,800.00 $7,800.00 1 $7,800.00
$436,886.30 $436,886.30
Item
Description of Items
Estimated Unit
Unit Cost
Estimated
Completed
Completed
No.
Quanity
Total
Quanity
Total
1
POST -CCTV INSPECTION (CO#1)
2366 LF
$3.00
$7,098.00
2366
$7,098.00
2
TRENCH SAFETY (CO#1)
2366 LF
$1.00
$2,366.00
2366
$2,366.00
3
CONCRETE ENCASEMENT FOR UTILITY PIP
9 CY
$330.00
$2,970.00
9
$2,970.00
4
10" SEWER CARRIER PIPE
20 LF
$50.00
$1,000.00
20
$1,000.00
5
MANHOLE VACUUM TESTING (CO#1)
8 EA
$150.00
$1,200.00
8
$1,200.00
6
4" SEWER SERVICE
121 EA
$1,590.00
$192,390.00
121
$192,390.00
7
8" SEWER PIPE (CO#1)
2246 LF
$55.00
£123,530.00
2246
$123,530.00
Monday, July 28, 2025 Page 2 of 5
City Project Numbers 104198 DOE Number 4198
Contract Name BRANDING IRON TOWNHOMES Estimate Number I
Contract Limits Payment Number 1
Project Type WATER & SEWER For Period Ending 7/18/2025
Project Funding
8
8" SEWER PIPE, CSS BACKFILL
60 LF
$86.00
$5,160.00
60
$5,160.00
9
8" SEWER PIPE, CLSM BACKFILL
60 LF
$109.00
$6,540.00
60
$6,540.00
10
EPDXY MANHOLE LINER (CO#1)
55.4 VF
$440.00
$24,376.00
55.4
$24,376.00
11
4' MANHOLE (CO#1)
6 EA
$4,670.00
$28,020.00
6
$28,020.00
12
4' DROP MANHOLE
2 EA
$4,810.00
$9,620.00
2
$9,620.00
13
4' EXTRA DEPTH MANHOLE
14 VF
$220.00
$3,080.00
14
$3,080.00
Sub -Total of Previous Unit
$407,350.00
$407,350.00
Monday, July 28, 2025 Page 3 of 5
City Project Numbers 104198
Contract Name BRANDING IRON TOWNHOMES
Contract Limits
Project Type WATER & SEWER
Project Funding
Contract Information Summary
Original Contract Amount
Change Orders
Change Order Number 1
Change Order Number 1
Total Contract Price
DOE Number 4198
Estimate Number I
Payment Number 1
For Period Ending 7/18/2025
$844,562.30
$7,050.00
($7,376.00)
$844,236.30
Total Cost of Work Completed $844,236.30
Less % Retained $0.00
Net Earned $844,236.30
Earned This Period $844,236.30
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
$844,236.30
Monday, July 28, 2025 Page 4 of 5
City Project Numbers 104198 DOE Number 4198
Contract Name BRANDING IRON TOWNHOMES Estimate Number I
Contract Limits Payment Number I
Project Type WATER & SEWER For Period Ending 7/18/2025
Project Funding
Project Manager NA City Secretary Contract Number
Inspectors M.GLOVER / MTERKINS Contract Date
Contractor BURNSCO CONSTRUCTION, INC. Contract Time 115 WD
6331 SOUTHWEST BLVD Days Charged to Date 134 WD
FORT WORTH, TX 76132 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 $844,236.30
Less % Retained $0.00
Net Earned $844,236.30
Earned This Period $844,236.30
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
$844,236.30
Monday, July 28, 2025 Page 5 of 5
IPROJECT NAME:
CO NTRACT:
ICFA#
ICITY PROJECT #
ICITY SECRETARY CONTRACT #
IFID#
IX #
IFILE #
INSPECTOR:
PROJECT MANAGER:
DEVELOPER -AWARDED -PROJECT CHANGE ORDER
Branding Iron
Water, Sewer, and Drainage
23-0102
104198
61645
30114-0200431-104198-EO7685
X-27408
K-3003
Jesse Cervantes
Sandip Adhikari
CITY PARTICIPATION:1 NO
Phone No: (469)490-7674
Phone No: (817)392-8424
I
WATER
SEWER
Developer
Cost
City Cost
Developer Cost
City Cost
IORIGINAL CONTRACT
$429,836.30
$0.00
I $414,726.00
$0.00
(EXTRAS TO DATE
$0.00
$0.00
$0.00
$0.00
(CREDITS TO DATE
$0.00
$0.00
I $0.00
$0.00
CONTRACT TO DATE
$429,836.30
$0.00
I $414,726.00
$0.00
(AMOUNT OF PROP. CHANGE ORDER
I $7,050.00 I
$0.00
($7,376.00)
$0.00
(REVISED CONTRACT AMOUNT
I $436,886.30 I
$0.00
I $407,350.00
I $0.00
TOTAL REVISED CONTRACT AMOUNT PER
UNIT
$436,886.30
$407,350.00
REVISED COST SHARE
Dev. Cost:
$1,000,909.80
TOTAL REVISED CONTRACT
CHANGE
ORDER No:
1
CONTRACT UNIT
DRAINAGE
PAVING
STREET
Developer
Developer
Developer
Cost City Cost
Cost City Cost
Cost
$156,673.50 $0.00
$0.00 $0.00
$0.00
$0.00 $0.00
$0.00 $0.00
$0.00
$0.00 $0.00
$0.00 $0.00
$0.00
$156,673.50 $0.00
$0.00 $0,00
$0.00
$0.00 $0.00
$0.00 $0.00
$0.00
$156,673.50 $0.00
$0.00 $0.00
$0.00
$156,673.50 I $0.00
City Cost: $0.00
$1,000,909.80
LIGHTS
$0.00
REVIEWED
By Sandip Adhikari at 5:39 pm, Jul 10, 2025
i
City Cost
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
CONTRACT
DAYS
50
Revised: 12-17-2018 Page 1
You are directed to make the following changes in the contract documents:
CITY BID ITEM
PAY ITEM #
#
�3312.2003
QUANTITY
15
5.00
CITY BID ITEM
PAY ITEM #
#
QUANTITY
I 3301.0020
(188)
1
2
3305.0109
(188)
5
3301.0101
(1)
7
3331.4115
(188)
10
3339.0001
19.4
11
3339.1001
(1) 1
I
Asterisk (*) indicates New Pay Item
UNIT 1: WATER IMPROVEMENTS
CFW Unit
UNIT
ITEM DESCRIPTION Price
EA
1" Water Service
TOTAL UNIT I: WATER IMPROVEMENTS
UNIT II: SANITARY SEWER IMPROVEMENTS
UNIT
ITEM DESCRIPTION
LF
Post -CCTV Inspection
LF
Trench Safety
EA
Manhole Vaccum Testing
LF
B" Sewer Pipe
VF
Epoxy Manhole Liner
EA
4' Manhole
TOTAL UNIT 11: SANITARY SEWER IMPROVEMENTS
Developer
UNIT PRICE Cost
$1410.00 $7,050.00
$7,050.00
Developer
UNIT PRICE
Cost
$3.00
($564.00)
$1.00
($188.00)
$150.00
($150.00)
$55.00
($10,340.00)
$440.00
$8,536.00
$4670.001
($4,670.00)
1
$0.00
($7,376.00)
REVIEWED
By Sandip Adhikari at 5:39 pm, Jul 10, 2025
City Cost
TOTAL I
$0.00
$7,050.00
$0.00
$7,050.00
City Cost
TOTAL
($564.00)
($188.00)
($150.00)
($10,340.00)
$8,536.00
($4,670.00)
$0.00
0
1
($7,376.00)
1
Revised: 12-17-2018 Page 2
REASONS FOR CHANGE ORDER Add irrigation services, update sewer services based on developer input, remove SS-D, added interior corrosion protection where required.
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.
RECOMME QED:
mma Inc. }I
By:
:�
Name: Andrea Tavlor. PE
Title: Principal
By:
Name:
Title:
By.
Name:
Title:
M&C Number:
M&C Date Approved:
Revised: 12-17-2018
APPROVAL RECOMMENDED:
CFW- Water Department
RECOMMENDED:
CFW - 'Contract Compliance Manager
APPROVED:
D.R. Horton - DFW West Dtwci&7
By:
Name: Justin Bosworth
Title: Assilanl Secrelary
APPROVED:
CFW - Assistant City Manager
By:
Name:
Title:
APPROOV�VEQI�gn BY /AumConstru i .Inc.
'
Name: J/hn Burns
Title: President
APPROVED AS TO FORM AND LEGALITY:
CFW- Assistant City Attorney
By.
Name:
Title:
ATTEST ' Contract Compliance Manager (Project Manager):
By signing I acknowledge that I am the person responsible
for the monitoring and administration of this contract, include
ensuring all performance and reporting requirements.
Jannelle S. Goodall
City Secretary QThere are NO City Funds associated with this Contract
❑ There are City Funds associated with this Contract
REVIEWED
By Sandip Adhikari at 5:39 pm, Jul 10, 2025
Page 3
FORTWORTH
TRANSPORTATION AND PUBLIC WORKS
PIPE REPORT FOR:
PROJECT NAME: Branding Iron Townhomes
CITY PROJECT NUMBER: 104198
WATER
PIPE LAID SIZE TYPE OF PIPE
C900 8" PVC
LF
2643'
FIRE HYDRANTS: 3 VALVES (16" OR LARGER) 0
PIPE ABANDONED SIZE TYPE OF PIPE LF
DENSITIES: Yes
NEW SERVICES: 1" Copper 121 EA
I SEWER
PIPE LAID SIZE TYPE OF PIPE LF
SDR-26 8" PVC 2434'
PIPE ABANDONED SIZE TYPE OF PIPE LF
DENSITIES: YES
NEW SERVICES: 4" PVC 121 EA
TRANSPORTATION AND PUBLIC WORKS
The City of Fort Worth • 1000 Throckmorton Street • Fort Worth, TX 76012-6311
FORT WORTH,
TRANSPORTATION AND PUBLIC WORKS
July 18, 2025
Burnsco Construction, Inc
6331 Southwest Blvd
Benbrook TX, 76132
RE: Acceptance Letter
Project Name: Branding Iron Townhomes
Project Type: Water & Sanitary Sewer
City Project No.: 104198
To Whom It May Concern:
On July 15, 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 July 18, 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 July 18, 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-
392-7830.
Sincerely,
_e
Sandip Adhikari, Project Manager
Cc: Michael Perkins, Inspector
Mike Glover, Inspection Supervisor
Randy Horton, Senior Inspector
Andrew Goodman, Program Manager
MMA Engineering, Consultant
Burnsco Construction, Contractor
D R Horton , Developer
File
E-Mail: TPW_Acceptance@fortworthtexas.gov
Rev. 8/20/19
AFFIDAVIT
STATE OF TEXAS
COUNTY OF TARRANT
Before me, the undersigned authority, a notary public in the state
and county aforesaid, on this day personally appeared Ab Grantges,
Contract Mgr, Of Burnsco Construction, known to me to be a credible
person, who being by me duly sworn, upon his oath deposed and said;
That all persons, firms, associations, corporations, or other
organizations furnishing labor and/or materials have been paid in full;
That the wage scale established by the City Council in the City of
Fort Worth has been paid in full;
That there are no claims pending for personal injury and/or
property damages;
On Contract described as;
Branding Iron Townhomes - Water, Sanitary Sewer and Storm Drain
BY j
b Grantges, tract Manager
Subscribed and sworn before me on this date 28th of July, 2025.
Notary Public
Tarrant County, Texas
KASSANDRA CANALES
Nolary Public, State of Texas
a}T, Come. Expires 01-23 2027
%'kort4 ` Notary ID 134158873
�IIIIS}j1`
CONSENT OF
SURETY COMPANY
TO FINAL PAYMENT
Conforms with the American Institute of
Architects, AIA Document G707
OWNER
❑
ARCHITECT
❑
CONTRACTOR
❑
SURETY
❑
OTHER
Bond No 022238771
PROJECT:
(name, address) Branding Iron - Water, Sanitary Sewer, and Drainage Improvements
TO (Owner)
Fort Worth TX
ID.R. HORTON-DFW WEST DIVISION AND CITY OF ARCHITECT'S PROJECT NO:
FORT WORTH CONTRACT FOR:
6751 North Freeway Branding Iron - Water, Sanitary Sewer, and Drainage Improvements
Fort Worth TX 76131 CONTRACT DATE:
CONTRACTOR: BURNSCO CONSTRUCTION, INC.
In accordance with the provisions of the Contract between the Owner and the Contractor as indicated above, the
(here insert name and address of Surety Company)
LIBERTY MUTUAL FIRE INSURANCE COMPANY
175 Berkeley Street
Boston MA 02116 , SURETY COMPANY
on bond of (here insert name and address of Contractor)
BURNSCO CONSTRUCTION, INC.
6331 Southwest Boulevard
Benbrook TX 76132
,CONTRACTOR,
hereby approves of the final payment to the Contractor, and agrees that final payment to the Contractor shall not relieve
the Surety Company of any of its obligations to (here insert name and address of Owner)
D.R. HORTON-DFW WEST DIVISION AND CITY OF FORT WORTH
6751 North Freeway
Fort Worth TX 76131
as set forth in the said Surety Company's bond.
IN WITNESS, WHEREOF,
the Surety Company has hereunto set its hand this
Attest: -
(Seal):
23rd day of July, 2025
LIBERTY MUTUAL FIRE INSURANCE COMPANY
Surety Company
Sin�Authorized Representative
Snnhinia Hunter
Title
, OWNER,
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
ONE PAGE
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Liberty POWER OF ATTORNEY
Mutual. Certificate No: 8213588-022020
SURETY Liberty Mutual Fire Insurance Company
Wausau, Wisconsin
KNOWN ALL PERSONS BY THESE PRESENTS: Liberty Mutual Fire Insurance Company, being a Wisconsin Corporation having its principal office in the City of Wausau, State of
Wisconsin does hereby make, constitute and appoint Don E. Cornell; Sophinie Hunter; Tina McEwan; Robbi Morales; Mikaela Peppers; Tonie Petranek; Ricardo J. Reyna;
Joshua Saunders; Kelly A. Westbrook
all of the city of Dallas state of TX each individually if there be more than one named, its true and lawful attorney(s)-in-fact, with full
power and authority hereby conferred in their/its name, place and stead, to sign, execute, acknowledge and deliver in their/its behalf, and as their/its act and deed, without power of
redelegation, as follows:
Bonds, undertakings, recognizances, contracts of indemnity, and all other surety obligations, as required, unlimited as to Dollar amount
and to bind the Company(ies) making this appointment thereby as fully and to the same extent as if such bond or undertaking was signed by the duly authorized officers of the
Company(ies), and all the acts of said attorney(s), pursuant to the authority herein given, are hereby ratified and confirmed.
AUTHORITY FOR MAKING APPOINTMENT OF ATTORNEYS -IN -FACT
Appointment of Attorneys -in -Fact by Liberty Mutual Fire Insurance Company are made pursuant to Article V, Section 10 of Liberty Mutual Fire Insurance Company's By -Laws, as
amended and by Unanimous Consent of the Board of Directors dated May 21st, 2013. Further, the President of Liberty Mutual Fire Insurance Company, executed a Delegation of
Authority and authorized the assistant secretary signing below to appoint attorneys -in -fact as may be necessary to act on behalf of Liberty Mutual Fire Insurance Company to make
execute, seal, acknowledge and deliver as surety any and all undertakings, bonds, recognizances, and other surety obligations. .2 0
IN WITNESS WHEREOF, Liberty Mutual Fire Insurance Company has caused these presents to be signed by its authorized representatives, and its Corporate Seal to be hereto affixed, c
this 2nd day of April 2025 r_
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INSG
Liberty Mutual fire Insurance Company
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By.
Nathan J. Zangerle, Assistant Secretary
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State of PENNSYLVANIA
County of MONTGOMERY ss
The foregoing instrument was acknowledged before me this 2nd day of April 2025
Insurance Company.
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CERTIFICATE
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Attest:LP07 - Q o
Heather B. Magee o 0
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by Nathan J. Zangerle, an authorized representative of Liberty Mutual Fire Insurance o
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Commonwealth of Pennsylvania - Notary Seal
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Teresa Pastella, Notary Public
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Montgomery County
My commission expires March 28, 2029
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By.
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Commission number 1126044
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Teresa Pastella, Notary Public
Member, Pennsylvania Association of Notaries
I, the undersigned, an Assistant Secretary of Liberty Mutual Fire Insurance Company, do hereby certify that the original power of attorney of which the foregoing is a full, true and correct
copy, is in full force and effect on the date of this certificate; and I do further certify that the officer or official who executed the said power of attorney was one of the officers or officials
specially authorized by the Board of Directors to appoint attorneys -in -fact as provided in the Unanimous Consent and Vote of the Board of Directors of Liberty Mutual Fire Insurance
Company dated May 21, 2013.
This certificate and the above power of attorney may be signed by facsimile or mechanically reproduced signatures under and by authority of the Board of Directors of Liberty Mutual Fire
Insurance Company evidenced by the Unanimous Consent and Vote of the Board of Directors dated June 28, 2006 wherein it was
VOTED that the signatures of such officers and the seal of the Company 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 signature and facsimile seal shall be valid and binding upon the Company when so affixed and in the future with respect to
any surety undertakings, bonds, recognizances and other surety obligations to which it is attached.
IN TESTIMONY WHEREOF, I have hereunto subscribed my name and affixed the corporate seal of the said company, affixed, this 23rd day of July 2025
PO
F1{tE INSG _
g 1908� � By:
o Renee C. Llewellyn, Assistant Secretary
Yd, �vsco"s��dD
LMS-22023 02/24
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TEXAS
IMPORTANT NOTICE
To obtain information or make a complaint:
You may call toll -free for information or to
make a complaint at
1-877-751-2640
You may also write to:
2200 Renaissance Blvd., Ste. 400
King of Prussia, PA 19406-2755
You may contact the Texas Department of
Insurance to obtain information on companies,
coverages, rights or complaints at
1-800-252-3439
You may write the Texas Department of Insurance
Consumer Protection (111-1A)
P. O. Box 149091
Austin, TX 78714-9091
FAX: (512) 490-1007
Web: httn://www.tdi.texas.aov
E-mail: ConsumerProtection4,tdi.texas.aov
PREMIUM OR CLAIM DISPUTES:
Should you have a dispute concerning your
premium or about a claim you should first
contact the agent or call 1-800-843-6446.
If the dispute is not resolved, you may contact the
Texas Department of Insurance.
ATTACH THIS NOTICE TO YOUR
POLICY:
This notice is for information only and does not
become a part or condition of the attached
document.
NP 70 68 09 01
LMS-15292 10/15
TEXAS
AVISO IMPORTANTE
Para obtener informacion o para someter una
queja:
Usted puede llamar al numero de telefono gratis
para informacion o para someter una queja al
1-877-751-2640
Usted tambien puede escribir a:
2200 Renaissance Blvd., Ste. 400
King of Prussia, PA 19406-2755
Puede comunicarse con el Departamento de
Seguros de Texas para obtener informacion
acerca de companias, coberturas, derechos o
quejas al
1-800-252-3439
Puede escribir al Departamento de Seguros
de Texas Consumer Protection (I I I -IA)
P. O. Box 149091
Austin, TX 78714-9091
FAX # (512) 490-1007
Web: httn://www.tdi.texas.aov
E-mail: ConsumerProtection4,tdi.texas.aov
DISPUTAS SOBRE PRIMAS O RECLAMOS:
Si tiena una disputa concerniente a su prima o a
un reclamo, debe comunicarse con el agente o
primero. Si no se resuelve la disputa, puede
entonces comunicarse con el departamento (TDI)
UNA ESTE AVISO A SU POLIZA:
Este aviso es solo para proposito de informacion
y no se convierte en parte o condicion del
documento adjunto.