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(3)ExperienceRatingForm.EachexperienceratedriskmayreceiveasinglecopyofitscurrentExperience
<br />RatingForm/WorksheetfreeofchargebycompletingaPolicyholderExperienceRatingWorksheet
<br />RequestFormontheWCIRB'swebsiteatwcirb.com/ratesheet.TheExperienceRatingForm/Worksheet
<br />willincludeaLoss-FreeRating,whichistheexperiencemodificationthatwouldhavebeencalculatedif
<br />$0(zero)actuallosseswereincurredduringtheexperienceperiod.Thishypotheticalratingcalculationis
<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 />YoumaysendusawrittenComplaintandRequestforActionrequestingthatwereconsiderachangeina
<br />classificationassignmentthatresultsinanincreasedpremiumand/orrequestingthatwereviewthemannerin
<br />whichourratingsystemhasbeenappliedinconnectionwiththeinsuranceaffordedorofferedyou.Written
<br />Complaints and Requests for Action should be forwarded to:
<br />Hartford Casualty Insurance Company
<br />One Pointe Drive, Suite 200, Brea, CA 92821; Telephone (800) 451-6944; Fax (860) 723-4289.
<br />AfteryousendyourComplaintandRequestforAction,wehave30daystosendyouawrittennotice
<br />indicatingwhetheryourwrittenrequestwillbereviewed.Ifweagreetoreviewyourrequest,wemustconduct
<br />thereviewandissueadecisiongrantingorrejectingyourrequestwithin60daysaftersendingyouthewritten
<br />noticegrantingreview.Ifwedeclinetoreviewyourrequest,ifyouaredissatisfiedwiththedecisionupon
<br />review,orifwefailtograntorrejectyourrequestorissueadecisionuponreview,youmayappealtothe
<br />Insurance Commissioner as described in paragraph II.C., below.
<br />B.DisputingtheActionsoftheWCIRB.Ifyouhavebeenaggrievedbyanydecision,action,oromissiontoact
<br />oftheWCIRB,youmayrequest,inwriting,thattheWCIRBreconsideritsdecision,action,oromissiontoact.
<br />Youmayalsorequest,inwriting,thattheWCIRBreviewthemannerinwhichitsratingsystemhasbeen
<br />appliedinconnectionwiththeinsuranceaffordedorofferedyou.Forrequestsrelatedtoclassification
<br />disputes,thereportingofexperience,orcoverageissues,yourinitialrequestforreviewmustbereceivedby
<br />theWCIRBwithin12monthsaftertheexpirationdateofthepolicytowhichtherequestforreviewpertains,
<br />exceptiftherequestinvolvestheapplicationoftheRevisionofLossesrule.Forrequestsrelatedtoyour
<br />experiencemodification,yourinitialrequestforreviewmustbereceivedbytheWCIRBwithin6monthsafter
<br />theissuance,or12monthsaftertheexpirationdate,oftheexperiencemodificationtowhichtherequestfor
<br />reviewpertains,whicheverislater,exceptiftherequestforreviewinvolvestheapplicationoftheRevisionof
<br />Lossesrule.IftherequestinvolvestheRevisionofLossesrule,thetimetostateyourappealmaybelonger.
<br />(See Section VI, Rule 7 of the ERP).
<br />YoumaycommencethereviewprocessbysendingtheWCIRBawrittenInquiry.WrittenInquiriesshouldbe
<br />th
<br />sentto:WCIRB,1901HarrisonStreet,17Floor,Oakland,CA94612,Attn:CustomerService.
<br />CustomerServicecanbereachedat888.229.2472(phone),415.778.7272(fax)and
<br />customerservice@wcirb.com (email).
<br />IfyouaredissatisfiedwiththeWCIRB'sdecisionuponanInquiry,oriftheWCIRBfailstorespondwithin90
<br />daysafterreceiptoftheInquiry,youmaypursuethesubjectoftheInquirybysendingtheWCIRBawritten
<br />ComplaintandRequestforAction.AfteryousendyourComplaintandRequestforAction,theWCIRBhas30
<br />daystosendyouwrittennoticeindicatingwhetheryourwrittenrequestwillbereviewed.IftheWCIRBagrees
<br />toreviewyourrequest,itmustconductthereviewandissueadecisiongrantingorrejectingyourrequest
<br />within60daysaftersendingyouthewrittennoticegrantingreview.IftheWCIRBdeclinestoreviewyour
<br />request,ifyouaredissatisfiedwiththedecisionuponreview,oriftheWCIRBfailstograntorrejectyour
<br />requestorissueadecisionuponreview,youmayappealtotheInsuranceCommissionerasdescribedin
<br />paragraphII.C.,below.WrittenComplaintsandRequestsforActionshouldbeforwardedto:WCIRB,1901
<br />th
<br />HarrisonStreet,17Floor,Oakland,CA94612,Attn:ComplaintsandReconsideration.TheWCIRB's
<br />contactinformationis888.229.2472(phone),415.371.5204(fax)andcustomerservice@wcirb.com
<br />(email).
<br />Form PN 04 99 01 I (02/22)Printed in U.S.A.Page2 of3
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