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COMPLAINT NOTICE: <br />DISPUTE RESOLUTION SERVICES <br />NCCI’S DISPUTE RESOLUTION PROCESS DOES NOT APPLY TO WORKERS COMPENSATION CLAIMS. <br />Forworkerscompensationclaimdisputes,see“CLAIMCOMPLAINT”below.Forissuesrelatedtoaviolationof <br />law related to your policy, see “VIOLATIONS OF LAW” below. <br />ImportantNote:ThedisputeresolutionservicesprovidedthroughtheDisputeResolutionProcess(Process)ofthe <br />NationalCouncilonCompensationInsurance(NCCI)arevoluntary.TheProcessisnotanadministrativeremedythat <br />mustbeexhaustedbeforeyoupursuereliefincourt.UsingtheProcessdoesnotpreventyouorthecarrierthatissued <br />the policy from pursuing any available legal remedies at any time. <br />NCCI can assist in the resolution of a dispute regarding your policy that is related to any of the following matters: <br />oTheapplicationorinterpretationofrulescontainedinthevariousNCCImanuals(including,butnotlimitedto, <br />classification codes and experience rating modifications) <br />oRating programs <br />oEndorsements <br />oForms <br />Contactthecarrierthatissuedthepolicyandattempttoresolvethedisputedirectly.Ifyouandthecarriercannotagree, <br />thencontactNCCItoaskforassistance.NCCI'sBasicManualrule,DisputeResolutionProcess,addressesdisputes. <br />Youmayobtaindisputeresolutionservicesonlyafteryouhavemadeareasonableattempttofirstresolvethedispute <br />directly with the carrier and after you have paid any undisputed premium due to the carrier. <br />SendyourrequestforassistancebymailtoNCCI,DisputeResolutionServices,901PeninsulaCorporateCircle,Boca <br />Raton, FL 33487-1362; or by fax to 561-893-5043; or by email to disputeresolution@ncci.com. <br />THISNOTICEOFTHEDISPUTERESOLUTIONPROCESSISFORINFORMATIONONLYANDDOESNOTBECOME <br />A PART, TERM, OR CONDITION OF THIS POLICY. <br />VIOLATIONS OF LAW: <br />Ifyoubelievetherehasbeenaviolationoflawrelatedtoyourpolicy,fileacomplaintwiththeTexasDepartmentof <br />Insurance: <br />Phone: 1-800-252-3439Online: tdi.texas.gov <br />Email: ConsumerProtection@tdi.texas.govMail: MC CO-CP, PO Box 12030, Austin, TX 78711-2030 <br />CLAIM COMPLAINT: <br />Ifthereisaworkerscompensationclaimcomplaintinvolvingoneofyouremployees,thencontacttheTexasDepartment <br />ofInsurance-DivisionofWorkers'Compensation,ComplianceandInvestigationsbymailtoMC:CI,POBox12050, <br />Austin, TX 78711-2050; or by fax to 512-490-1030; or by email to DWCCOMPLAINTS@tdi.texas.gov. <br />THISNOTICEISFORINFORMATIONONLYANDDOESNOTBECOMEAPART,TERM,ORCONDITIONOFTHIS <br />POLICY. <br />Form WC 42 03 01 LPrinted in U.S.A.Page3 of3 <br /> <br />