HomeMy WebLinkAboutContract 34488-FP1 Deprbnw ofJP&W Const,Services
Dat
Project nary SCR TAIM r
Risk Management J.Page _ IT WORTH. ��� ��T ,jo,
D.O.E. Brotherton
CFA Westerman/Scanned -- P�2(o0 Q350
The Pmcesding people have hs Cndbaed conceningum request br*W p
payment a have released Osis project for such ATION AND PUBLIC WORKS e-5 344 Ye
Clearance Conducted By Shamelts Kennedy F PROJECT COMPLETION
D.O.E.Mr. 7288
Rtgac+cling contract U7288 for THE 8AIrtCI M EAST ADDN PH 2-WATER&SEWER as required by the
WATER DEPARTMENT as approved by City Council on N/A through M&C N/A the director of the
WATER DEPARTMENT upon the reca&Qenclation of the Assistant Director of the Transportation&Public Works
Department has accepted the project as c I D n„�
Original Contract Prices: �a S413,346.60
Amount of Approved Change Orders: $10,860.00 Ne 1
BY
Revised Contract Amount: $424,206,60
Total Cost Work Completed: 5424,206.60
Less Deductions:
Liquidated Damages: Days Q$210.00/Day
Pavement Deficiencies:
Total Deduction Amount:
Total Cost Work Completed: 5424,206.60
Less Previous Payments: $0.00
Final Payment Due 5424,206.60
Recommended or Acceptance Date
Asst. Director, TPW- Infrastructure Design and Construction
- 2r-a�t�r-
Accepte
ld Date
st. Director, WATER DEPARTMENT
t. City Manager Date
Comments: P265-541200-607150235083,P275-541200-707130235083
WPM SUP s 0 � OFFICIAL RECORD
CITE' SECRETARY
°. '44OR'T111 TX
FORT WORTH
CITY OF FORT WORTH
FINAL PAYMENT REQUEST
Contract Name THE RANCHES EAST ADDITION PHASE 11
Contract Limits
Project Type WATER&SEWER
City Project Numbers 02350
DOE Number 7288
Estimate Number I Payment Number I For Period Ending 9/2/2015
CD
City Secretary Contract Number 117288 Contract Time 15CD
Contract Date Days Charged to Date 218
Project Manager Ehia Contract is 100.00 Complete
Contractor BURNSCO CONSTRUCTION,INC.
6331 SOUTHWEST BLVD
FORT WORTH, TX 76132
Inspectors LAYER / TAEZAZ
Wednesday,September 02,2015 Page 1 of 5
City Project Numbers 02350 DOE Number 7288
Contract Name THE RANCHES EAST ADDITION PHASE 11 Estimate Number 1
Contract Limits Payment Number I
Project Type WATER&SEWER For Period Ending 9/2/2015
Project Funding
WATER
Item Estimated Estimated Completed Completed
Description of Items Unit Unit Cost
No. Quanity Total Quanity Total
1 TRENCH SAFETY 4971 LF $0.10 $497.10 4971 $497.10
2 UTILITY MARKERS 1 LS $100.00 $100.00 1 $100.00
3 VALVE BOX ADJUSTMENT 1 EA $150.00 $150.00 1 $150.00
4 DUCTILE IRON WATER FITTINGS 1.52 IN $8,000.00 $12,160.00 1.52 $12,160.00
W/RESTRAINT
5 6"PVC WATER PIPE 62 LF $16.00 $992.00 62 $992.00
6 8"PVC WATER PIPE 4112 LF $17.50 $71,960.00 4112 $71,960.00
7 12"PVC WATER PIPE 797 LF $47.00 $37,459.00 797 $37,459.00
8 FIRE HYDRANT 6 EA $2,500.00 $15,000.00 6 $15,000.00
9 CONNECTION TO EXISTING 4"-12"WATER 4 EA $700.00 $2,800.00 4 $2,800.00
MAIN
10 V WATER SERVICE 102 EA $710.00 $72,420.00 102 $72,420.00
11 6"GATE VALVE 5 EA $800.00 $4,000.00 5 $4,000.00
12 8"GATE VALVE 8 EA $1,200.00 $9,600.00 8 $9,600.00
13 12"GATE VALVE 4 EA $2,100.00 $8,400.00 4 $8,400.00
14 1 1/2"IRRIGATIONCO#2 6 EA $1,500.00 $9,000.00 6 $9,000.00
15 34"IRRIGATION CONDUITS CO#2 120 LF $15.50 $1,860.00 120 $1,860.00
Sub-Total of Previous Unit $246,398.10 $246,398.10
SEWER
Item Description of Items Estimated Unit Unit Cost Estimated Completed Completed
No. Quanity Total Quanity Total
1 PRE-CCTV INSPECTION 3013 LF $1.00 $3,013.00 3013 $3,013.00
2 POST-CCTV INSPECTION 3013 LF $1.40 $4,218.20 3013 $4,218.20
3 MANHOLE VACUUM TESTING 20 EA $100.00 $2,000.00 20 $2,000.00
4 EXPLORATORY EXCAVATION OF EXISTING 1 EA $500.00 $500.00 1 $500.00
UTILITIES
5 MANHOLE ADJUSTMENT MAJOR 3 EA $1,520.00 $4,560.00 3 $4,560.00
6 TRENCH SAFETY 3013 LF $0.10 $301.30 3013 $301.30
7 TRENCH WATER STOPS 15 EA $250.00 $3,750.00 15 $3,750.00
8 4"SEWER SERVICE&2 WAY CLEANOUT 79 EA $580.00 $45,820.00 79 $45,820.00
9 4"2 WAY CLEANOUT 22 EA $120.00 $2,640.00 22 $2,640.00
Wednesday,September 02,2015 Page 2 of 5
City Project Numbers 02350 DOE Number 7288
Contract Name THE RANCHES EAST ADDITION PHASE If Estimate Number I
Contract Limits Payment Number I
Project Type WATER&SEWER For Period Ending 9/2/2015
Project Funding
10 8"SEWER PIPE CSS BACKFILL 80 LF $31.00 $2,480.00 80 $2,480.00
11 8"SEWER PIPE SELECT BACKFILL 2933 LF $22.00 $64,526.00 2933 $64,526.00
12 T MANHOLE 20 EA $2,000.00 $40,000.00 20 $40,000.00
13 4'EXTRA DEPTH-MANHOLE BEYOND 6' 40 VF $100.00 $4,000.00 40 $4,000.00
DEPTH
Sub-Total of Previous Unit $177,808.50 $177,808.50
Wednesday,September 02,2015 Page 3 of 5
City Project Numbers 02350 DOE Number 7288
Contract Name THE RANCHES EAST ADDITION PHASE 11 Estimate Number I
Contract Limits Payment Number I
Project Type WATER&SEWER For Period Ending 9/18015
Project Funding
Contract Information Summary
Original Contract Amoot $413,346.60
Change Orders
Change Order Number 1 $10,860.00
Total Contract Price 5424,206.60
Total Cost of Work Completed $424,206.60
Con Less •/.Retained 50.00
/ Net Earned 5424,206.60
Inspection Date Earned This Period 5424,206.60
� � Retainage This Period 50.00 Date j // Leu Liquidated Damages
Project M
Days @ /Day 50.00
Date �s� LessPavement Deficiency SO•00
s irector/rP -Infrastru Design and Construction Less Penalty 50.00
Date 7 -c"�'/ Less Previous Payment 50.00
recto?/C g Department Plus Material on Hand Less 15% $0.00
' .! Balance Due This Payment $424,206.60
Wednesday,Septmber 02,2015 Page 4 of 5
aC%,roV ® am
City Project Numbers 02350 DOE Number 7288
Contract Name THE RANCHES EAST ADD1110N PHASE II Estimate Number I
Contract Limits Payment Number 1
Project Type WATER&SEWER For Period Ending 9fMols
Project Funding
Project Manager Ehin City Secretary Contract Number 117299
Inspectors LAYER / TAEZAZ Contract Date
Contractor BURNSCO CONSTRUCTION,INC. Contract Time 150 CD
6331 SOUTHWEST BLVD Days Charged to Date 219 CD
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 $424,206.60
Less %Retained $0.00
Net Earned $424,206.60
Earned This Period $424,206.60
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 $424,206.60
Wednesday,September 02,2015 Page 5 of 5
FORTWORTH rev 03/05/07
TRANSPORTATION& PUBLIC WORKS
FINAL STATEMENT OF CONTRACT TIME
FINAL STATEMENT NO.:1
NAME OF PROJECT: The Ranches East Addition Phase 2
PROJECT NO.: 2350 CONTRACTOR: Burnsco Casstru€ction
DOE NO.: 7288
PERIOD FROM:01/20/15 TO: 08/31/15 FINAL INSPECTION DATE: 13-Aug-15
WORK ORDER EFFECTIVE:1/26/2015 CONTRACT TIME: 150 ®VVD a CIE
DAY OF DAYS REASON FOR DAYS DAY OF DAYS REASON FOR DAYS
MONTH CHARGED CREDITED MONTH CHARGED CREDITED
DURING DURING
1. 16.
2. 17.
3. 18.
4. 19.
5. 20.
6. 21.
7. 22.
8. 23.
9. 24.
10. 25.
11. 26.
12. 27.
13. 28.
14. 29.
15. 30.
31.
SAT,SUN, RAIN,TOO WET, UTILITIES DAYS TOTAL
&HOLIDAYS &TOO COLD RELOCATIONS OTHERS* CHARGED DAYS
THIS 0 0 0 0 218
PERIOD
PREVIOUS 0 0 0 0 0 0
PERIOD
TOTALS 0 0 0 0 218
TO DATE
*REMARKS:
X
CONTRAC,VR DATE INSPECTOR DATE
ENGINEERING DEPARTMENT
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
PIPE REPORT FOR:
PROJECT NAME: The Ranches East Addition Phase 2
PROJECT NUMBER: 2350
DOE NUMBER: 7288
WATER
PIPE LAID SIZE TYPE OF PIPE LF
Yes 6" PVC 62
Yes 8" PVC 4112
Yes 12 PVC 797
FIRE HYDRANTS: 6 VALVES(16"OR LARGER)
PIPE ABANDONED SIZE TYPE OF PIPE LF
No
DENSITIES: Yes
NEW SERVICES:
SEWER
PIPE LAID SIZE TYPE OF PIPE LF
Yes 8" PVC 2933
PIPE ABANDONED SIZE TYPE OF PIPE LF
No
DENSITIES: Yes
NEW SERVICES: 4" PVC 2425
i
i
TRANSPORTATION AND PUBLIC WORKS
The City of Fort Worth• 1000 Throckmorton Street•Fort Worth,TX 76012-6311
(817)392-7941•Fax:(817)392-7845
i
i
I
i
FORTWORTHREV:01122/07
TRANSPORTATION AND PUBLIC WORKS
CONTRACTOR'S EVALUATION OF CITY
1)PROJECT INFORMATION Date: 8/31/2015
Name of Contractor Project Name
Burnsco Construction Inc. The Ranches East Addition Phase 2
DOE Inspector Project Manager
7288 Fred
DOE Number Project Difft Ty
of Contract
2350 10 Simple O Routine O Complex ❑Water ❑ "Water O Storm Drainage O Pavement
Initial Contract Amount Final Contract Amount
$413,346.60 $424,206.60
II)PERFORMANCE EVALUATION
0-Inadequate 1-Deficient 2-Standard 3-Good 4-Excellent
ELEMENT RATING ELEMENT RATING
(0-4) (0-4)
INSPECTION EVALUATION PLANS&SPECIFICATIONS
1 Availability of Inspector 1 Accuracy of Plans to Existing Conditions
2 Knowledge of Inspector 2 Clarity&Sufficiency of Details
3 Accuracy of Measured Quantities 13 Applicability of Specifications
4 Display Of Professionalism 4 Accuracy of Plan Quantities
5 Citizen Complaint Resolution PROJECT MANAGER EVALUATION
6 Performance-Setting up Valve Crews,Labs 1 Knowledge And/Or Problem Resolution
ADMINISTRATION U 2 Availability of Project Manager u
1 Change Order Processing Time Qk 3 Communication
2 Timliness of Contractor Payments 14 Resolution of Utility Conflicts 0
3 Bid Opening to Pre-Con Meeting Timeframe
IID COMMENTS&SIGNATURES
COMMENTS
Signature Contractor
Signature DOE Inspector �)r
Signature DOE Inspector's Supervisor
INSPECTOR'S COMMENTS
TRANSPORTATION AND PUBLIC WORKS
t
The City of Fort Worth•1000 Throckmorton Street•Fort Worth,TX 76012-6311
(817)392-7941 •Fix:(817)392-7845
FORTWORTHREV:00/07
TRANSPORTATION AND PUBLIC WORKS
PERFORMANCE EVALUATION OF CONTRACTOR
I) CONTRACTOR&PROJECT DATA
Name of Contractor Project Name
Burnsco Construction Inc. The Ranches East Addition Phase 2
DOE Inspector DOE Number
Habte Taezaz 7288
DOE Inspector Project Manager
O Water O Waste Water ❑ Storm Drainage ❑ Pavement Fred
Initial Contract Amount Project Difficulty
$413,346.60 0 Simple O Routine O Complex
Final Contract Amount Date
$424,206.60 8/31/2015
H)PERFORMANCE EVALUATION
0-Inadequate I-Deficient 2-Standard 3-Good 4-Excellent
ELEMENT WEIGHT(x) APPLICABLE(Y/N) RATING(0-4) MAX SCORE SCORE
1 Submission of Documents 2 Y 3 8 6
2 Public Notifications 5 N
3 Plans on Site 5 Y 3 20 15
4 Field Supervision 15 Y 3 60 45
5 Work Performed 15 Y 3 60 45
6 Finished Product 15 Y 3 60 45
7 Job Site Safety 15 Y 4 60 60
8 Traffic Control Maintenance 15 Y 4 60 60
9 Daily Clean Up 5 Y 3 20 15
10 Citizen's Complaint Resolution 5 Y 4 20 20
11 Property Restoration 5 Y 3 20 15
12 After Hours Response 5 N
13 Project Completion 5 Y 3 20 15
TOTAL ELEMENT SCORE(A) 341
BONUS POINTS(25 Maximum)(B)
TOTAL SCORE(TS) 341
III)CONTRACTOR'S RATING
Maximum Score(MS)=448 or sum of applicable element score maximums which— 408
Rating([TS/MS]•100%) 341 / 408 — 84%
Performance Category Excellent
<20%=Inadequate 20'16 to<40%=Deficient 40%to<60%=Standard 60%to<80%=Good >_80%=Excellent
Inspector's Comments(INCLUDING EXPLANATION OF BONUS POINTS AWARDED)
Signature DOE Inspector, 61 Signature Contractor del
Signature DOE Inspector's Supervisorr!� -_
CONTRACTOR'S COMMENTS
TRANSPORTATION AND PUBLIC WORKS
, a< The City of Fort Worth-1000 Throckmorton Street-Fort Worth,TX 76012-6311
(817)392-7941 -Fax:(817)392-7845
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,Inc.,known to me to be a credible
person,who being by me duly sworn,upon his oath deposed and said;
That all persons, firms,associations,corporations,or other
organizations furnishing labor and/or materials have been paid in full;
That the wage scale established by the City Council in the City of
Fort Worth has been paid in full;
That there are no claims pending for personal injury and/or
property damages;
On Contract described as;
The Ranches East Phase 2- Water, Sanitary Sewer, Storm Drain and
BY
Ab Grantg , Contract Manager
Subscribed and sworn before me on this date 14th of August,2015.
Notary Public WAUKH
Tarrant County,Texas Wh►Cone E10000
June 26.2016
CONSENT OF OWNER ❑
SURETY COMPANY ARCHITECT ❑
CONTRACTOR ❑
TO FINAL PAYMENT SURETY ❑
Conforms with the American institute of OTHER
Architects,AIA Document G707
Bond No 022048407
PROJECT:
(name, address)The Ranches East Addition Phase II
TO (Owner)
ID.R.HORTON-TEXAS,LTD AND CITY OF FORT ARCHITECT'S PROJECT NO:
WORTH CONTRACT FOR:
6751 North Freeway The Ranches East Addition Phase II
Lod Worth TX 76131 J CONTRACT DATE:
CONTRACTOR:BURNSCO CONSTRUCTION,INC.
In accordance with the provisions of the Contract between the Owner and the Contractor as indicated above,the
Owe Insert name and address of Surety Company)
LIBERTY MUTUAL INSURANCE COMPANY
175 Berkeley Street
Boston MA 02116 , SURETY COMPANY
on bond of Thera 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 (hare Insert name and address of Owner)
D.R.HORTON-TEXAS,LTD AND CITY OF FORT WORTH
6751 North Freeway
Fort Worth TX 76131 , OWNER,
as set forth in the said Surety Company's bond.
IN WITNESS,WHEREOF,
the Surety Company has hereunto set its hand this 12th day of August,2015
LIBERTY MUTUAL INSURANCE COMPANY
Surn Company
Attest:Robbi Morales ZUz
(Seal): Signature of Authorized Representative
Soohinie Hunter Attorneyjn-Fact
Title
NOTE; This form is to be used as a companion document to AIA DOCUMENT 0706, CONTRACTOR'S AFFIDAVIT OF PAYMENT OF DEBTS AND CLAIMS,
ONE PAGE
THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS PRINTED ON RED BACKGROUND.
This Power of Amomey limits the ads of time named berek%and they have no authortly to bind the Company except in the manner and to the extent herein stated.
Certificate No.6901099
American Fire and Casually Company Liberty Mutual Insurance Company
The Ohio Casually Insurance Company West American insurance Company
POWER OF ATTORNEY
KNOWN ALL PERSONS BY THESE PRESENTS:That American Fire&Casualty Company and The Ohio Casualty Insurance Company are corporations duly organized under the laws of
the State of New Hampshire,tllat Liberty Mutual Insurance Comparry is a cxxporahm duly organized under the laws of tie State of Massachusetts,and West American Insurance Company
is a corporation duty organized under the lam of the State of Indiana(herein collectively caped it*'Companiesj,pursuant to and by authority herrn set forth,does hereby name,constitute
and appoint, Don E.Cornell:KaRV A.Westbrook;Use M.Bwrk*,,Ricardo J.Reyna;Robbi Morar,Sophinie Hunter.V.DeLene Marshall
all of the city of Daum stalls of TX each individually it thda be more than one named,Its true and b"I attorney-in fact to make,execute,seal,acknowledge
and deliver,for and on its behalf as surely and ua its act and deed,any and all undert ici gs,bonds,rec ogntzences and other surety obligations,In pursuance of these presents and sial
be as binding upon the Companies as it they have been duly signed by the president and attested by the secretary of the Companies in their own proper persons.
IN WITNESS WHEREOF,this Power of Attorney has been subscribed by an authorized officer or official of the Companies and the corporate seals of the Cornpanies have been affixed
11ii o ft1ph day of M.rcn 2015
�j 0 G1a•� �ZY INSVx115UR uuu American Fee and Casualty Company
'ti�� "' � The Ohio Casually Insurance Company
1906 0 0 1919 c 1912 ; 1991 39Liberty Mutual Insurance Company 241
West n Insurance Company
6 ; 3 Z = dl
3 .st ib Wil Y
m By:
STATE OF PENNSYLVANIA as David M.Carey,Assistant Secretary
COUNTY OF MONTGOMERY C
m On titre 10thday of M&Th 2015.before me personally appeared David M.Carey,who acknowledged himself to be the Assistant Secretary of American Fre and v F.
us Casualty Company,Liberty Mutual Insurance Company,The Ohio Casually Insurance Company,and West American Insurance Compan and that he,as such,being authorized so to do, >,y
6 2 execute the foregoing instrument for the purposes therein contained by signing on behalf of the corpwWris by himself as a duly authorized officer. LU
`re > IN WITNESS WHEREOF I have hereunto subscribed m name and affixed my notarial seal at Plymouth Meeting,Pennsylvania,on the day and yew fist above written. O Q.
�' d0 pts COMMONWEALTH OF PENNSYLVANIA Q 0
x°1°'►r4�1� TaN001111,11111Nal �.y'w�� �- w
�Qa � v s'► mp Paa6Nla.Ndary P11bire By: O
o L of Ph*�1 lon *kw Umc �hrY TenrKa PatOeMa,Mob"Pubk 0 C
` My carm,a,anan E>�is uairh Ze,�1T
.09
m Membw.Pennft1 nl\Msocairon of NoWles 0 E
c� This Power ofAttomey is made and executed pursuant to an by authority of the following Bylaws and Authorizations of American Fre and Casualty Company,The Oho Casualty Insurance oro O
w Company,Liberty Mutual Insurance Company,and WestAmerican Insurance Company which resolutions are now n full force and effect reading as blows: Q
NO ARTICLE IV—OFFICERS—Section 12.Power of Ab rley.Any dker or other o(kW of the Corporation andhorized for that purpose in writing by the Chairman or the President,and subjed O e
$ to such limitation as the Chairman or the President may prescribe,shall appoint such aticaneys4rrfad,as may be necessary to ant in behalf of the Corporation to make,execute,seal. m
o E adxnowledge and delver as surety any and all undertakings.bonds,recogntxances and other surely obligations.Such attorneys-irg"subled to the tinrlatiors set forth n their respective
E m powers of attOnhey,shall have kd poww b bind the Corporation by their eigrature and executlon of any,such instruments and to attach thereto the seal of the Corporation. When so of
+Q E executed,such Instruments shall be as binding as I signed by the President arc attested b by the Secretary Any pow or authority granted b any representative or attorney Iriak t under >c
V A the provisions d this article may be revoked at any time by the Board,the Chairmen,the President or by the officer or ofRcers granting such pourer or authority. t IV
M C ARTICLE Xilf—Exeartbn of Contracts—SECTION 5.Surety Bonds and Undertakl I
> m and subject to such limitations as the caiman or the �•�Y offfoor off the Company authored for third purpose n writing by the chairman or the president, N
�,C president may prescribe.shall appoint such as may be necessary to ad in behalf of the Cargany t0 make.execute. can?S seal.adonowledge and derm as suety any and art undertald gs,bonds,mcogrrzsnces and other surely obligations. Such sttomeyx- fact subject to the HmftBdm set brth n their C eQ
respective powers of attorney,shall have full power to bind the Company by their sigraWm and execution of any such instruments and to attach thereto the seal of the Compaty.When so cos 0
executed such Instruments shall be as binding as I signed by the president and atlested by the secretary, ~019
Certificate of Designation—The President of the Company,acting pursuant to the Bylaws of the C Impart,authorizes David M.Carey.Assistant Secretary to appoint such at1orr ts•in-
fad as may be necessary b ad on behalf of the Company to make,execute,seal,acaowwledge and deliver as surety any,and all undertakirgs,bonds,recog and other surety
obfigaticns.
Autl+onhatlah—By unanimous consent of the Company's Board of Directors,the Company consents that facsimile or mechanically reproduced signature of any assistant secretary of the
Company,wherever appearing upon a certified copy of any power of attorney issued by the Company in connection with surety bonds,shall be valid and binding upon the Company with
the same force and allied as t ao manually affixed.
I,Gregory W.Davenport,the undersigned,Assistant Secretary,of American Fire and Casualty Company,The ONo Casualty insurance Company,Liberty Mutual Insurance Company,and
West American Insurance Company do hereby nerdy that the*#nal power of attorney of which the foregoing Is a full,true and correct copy of the Pourer of Attorney executed by said
Companies,is In full force and effect and las not been revoked. ]�
IN TESTIMONY WHEREOF,I have hereunto set my hand and affixed thhe seals of said Companies thfs—6r_day d �!"�� 1i S4 ,20�.
*aD C,iSL ,tY INSU '�1NSUq, 5A1NSU.'
Z �!
S 1906 p o 1919 n > 1912 1991 3 By:
Qogory tit.Dtvenpork An Writ 8eentany
'A . P
* * * *
2460500
LMS 12873_122013
Li bert�'
SURETY
Important Notice
TO OBTAIN INFORMATION OR TO MAKE A COMPLAINT:
You may write to Liberty Mutual Surety at:
Liberty Mutual Surety
Interchange Corporate Center
450 Plymouth Road, Suite 400
Plymouth Meeting, PA 19462-8284
You may contact the Texas Department of Insurance to obtain information on
companies, coverages, rights or complaints at:
1-800-252-3439
You may write the Texas Department of Insurance:
P. O. Box 149104
Austin, TX 78714-9104
Fax: (512) 475-1771
Web: http://www.tdi.state.tx.us
E-mail: ConsumerProtection(a)tdi.state.tx.us
Premium or Claim Disputes
Should you have a dispute concerning a premium, you should contact the agent first. If you
have a dispute concerning a claim, you should contact 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.
LWG-3500