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<br />STATE <br />COMPENSATION <br />INSURANCE <br />FUND <br />HOME OFFICE <br />SAN FRANCISCO <br /> <br />ENDORSEMENT AGREEMENT <br />MEDICAL PROVIDER NETWORK <br /> <br />1801464-07 <br />RENEWAL <br />SG <br /> <br />EFFECTIVE OCTOBER 1, 2007 AT 12.01 A.M. <br /> <br />PAGE <br /> <br />2 OF <br /> <br />3 <br /> <br />ALL EFFECTIVE DATES ARE <br />AT 12:01 AM PACIFIC <br />STANDARD TIME OR THE <br />TIME INDICATED AT <br />PACIFIC STANDARD TIME <br /> <br />ADVANCED TRNSPRTTN CNCPTS GRP, INC <br />14 SORENSON <br />IRVINE, CA 92602 <br /> <br />CONTINUED. <br /> <br />TO BE TREATED BY A PHYSICIAN OF HIS OR HER CHOICE FROM <br />WITHIN THE MEDICAL PROVIDER NETWORK AFTER THE FIRST VISIT. <br />THE POLICYHOLDER SHALL NOTIFY EMPLOYEE OF THE METHOD BY <br />WHICH THE LIST OF PARTICIPATING PROVIDERS MAY BE ACCESSED <br />BY EMPLOYEES. <br /> <br />IT IS FURTHER AGREED THAT IF AN INJURED EMPLOYEE DISPUTES <br />EITHER THE DIAGNOSIS OR THE TREATMENT PRESCRIBED BY THE <br />TREATING PHYSICIAN, THE EMPLOYEE MAY SEEK THE OPINION OF <br />ANOTHER PHYSICIAN WITHIN THE MEDICAL PROVIDER NETWORK. IF <br />THE INJURED EMPLOYEE DISPUTES THE DIAGNOSIS OR TREATMENT <br />PRESCRIBED BY THE SECOND PHYSICIAN, THE EMPLOYEE MAY SEEK <br />THE OPINION OF A THIRD PHYSICIAN WITHIN THE MEDICAL <br />PROVIDER NETWORK. <br /> <br />IT IS FURTHER AGREED THAT THIS ENDORSEMENT IN NO WAY <br />AFFECTS THE RIGHTS OF AN INJURED WORKER TO PREDESIGNATE A <br />PHYSICIAN. AN EMPLOYEE MUST FILE WRITTEN NOTICE OF THE <br />PREDESIGNATION WITH THE EMPLOYER PRIOR TO THE DATE OF <br />INJURY. THE NOTICE MUST INCLUDE THE PHYSICIAN'S SIGNATURE <br />OF AGREEMENT TO THE PREDESIGNATION, AND THE FOLLOWING <br />CONDITIONS MUST APPLY: <br /> <br />THE PHYSICIAN IS THE EMPLOYEE'S REGULAR PHYSICIAN. <br /> <br />THE PHYSICIAN IS THE EMPLOYEE'S PRIMARY CARE PROVIDER WHO <br />HAS PREVIOUSLY DIRECTED THE MEDICAL TREATMENT OF THE <br /> <br />CONTINUED <br /> <br />NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE <br />OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS <br />POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE <br />HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR <br />LIMITATIONS OF THIS ENDORSEMENT. <br /> <br />COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: <br /> <br /> <br /> <br />~EPRESENTATIV <br />selF FORM 10217 (REV.3-07) <br /> <br /> <br />SEPTEMBER 14, 2007 <br /> <br />~(~~- <br /> <br />2437 <br /> <br />PRESIDENT <br /> <br />OLD DP 217 <br />