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(3) Experience Rating Form. Each experience rated risk may receive a single copy of its current Experience
<br />Rating Form/Worksheet free of charge by completing a Policyholder Experience Rating Worksheet
<br />Request Form on the WCIRB's website at wcirb.com/ratesheet. The Experience Rating Form/Worksheet
<br />will include a Loss -Free Rating, which is the experience modification that would have been calculated if
<br />$0 (zero) actual losses were incurred during the experience period. This hypothetical rating calculation is
<br />provided for informational purposes only.
<br />II. Dispute Process
<br />You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1.
<br />A. Our Dispute Resolution Process.
<br />You may send us a written Complaint and Request for Action requesting that we reconsider a change in a
<br />classification assignment that results in an increased premium and/or requesting that we review the manner in
<br />which our rating system has been applied in connection with the insurance afforded or offered you. Written
<br />Complaints and Requests for Action should be forwarded to:
<br />Trumbull Insurance Company
<br />One Hartford Plaza, T.4.175, Hartford, CT 06155; Telephone (800) 451-6944; Fax (860) 723-4289.
<br />After you send your Complaint and Request for Action, we have 30 days to send you a written notice
<br />indicating whether or not your written request will be reviewed. If we agree to review your request, we must
<br />conduct the review and issue a decision granting or rejecting your request within 60 days after sending you
<br />the written notice granting review. If we decline to review your request, if you are dissatisfied with the decision
<br />upon review, or if we fail to grant or reject your request or issue a decision upon review, you may appeal to
<br />the Insurance Commissioner as described in paragraph II.C., below.
<br />B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission to act
<br />of the WCIRB, you may request, in writing, that the WCIRB reconsider its decision, action, or omission to act.
<br />You may also request, in writing, that the WCIRB review the manner in which its rating system has been
<br />applied in connection with the insurance afforded or offered you. For requests related to classification
<br />disputes, the reporting of experience, or coverage issues, your initial request for review must be received by
<br />the WCIRB within 12 months after the expiration date of the policy to which the request for review pertains,
<br />except if the request involves the application of the Revision of Losses rule. For requests related to your
<br />experience modification, your initial request for review must be received by the WCIRB within 6 months after
<br />the issuance, or 12 months after the expiration date, of the experience modification to which the request for
<br />review pertains, whichever is later, except if the request for review involves the application of the Revision of
<br />Losses rule. If the request involves the Revision of Losses rule, the time to state your appeal may be longer.
<br />(See Section VI, Rule 7 of the ERP).
<br />You may commence the review process by sending the WCIRB a written Inquiry. Written Inquiries should be
<br />sent to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Customer Service. Customer Service
<br />can be reached at 888.229.2472 (phone), 415.778.7272 (fax) and customerservice cawcirb.com (email).
<br />If you are dissatisfied with the WCIRB's decision upon an Inquiry, or if the WCIRB fails to respond within 90
<br />days after receipt of the Inquiry, you may pursue the subject of the Inquiry by sending the WCIRB a written
<br />Complaint and Request for Action. After you send your Complaint and Request for Action, the WCIRB has 30
<br />days to send you written notice indicating whether or not your written request will be reviewed. If the WCIRB
<br />agrees to review your request, it must conduct the review and issue a decision granting or rejecting your
<br />request within 60 days after sending you the written notice granting review. If the WCIRB declines to review
<br />your request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to grant or reject your
<br />request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in
<br />paragraph II.C., below. Written Complaints and Requests for Action should be forwarded to: WCIRB, 1221
<br />Broadway, Suite 900, Oakland, CA 94612, Attn: Complaints and Reconsideration. The WCIRB's contact
<br />information is 888.229.2472 (phone), 415.371.5204 (fax) and customerserviceawcirb.com (email).
<br />Form PN 04 99 01 G (03/19) Printed in U.S.A.
<br />Rime Mattagmient DMsion
<br />REVIEWED&APPRDVEDBY:
<br />'� Risk Management Analyst
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