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<br />OIATc <br />COMPENSATION <br />INSURANCE <br />FUND <br /> <br />POLICYHOLDER NOTICE <br />YOUR RIGHT TO RATING AND DIVIDEND INFORMA TJON <br />PN 04 99 018 (Ed. 03-03) <br /> <br />Page 1 of 2 <br /> <br />POLICY NO. 1801464-07 <br />NR SG <br /> <br />ADVANCED TRNSPRTTN CNCPTS GRP, INC <br />14 SORENSON <br />IRVINE, CALiF 92602 <br /> <br />1. RATING AND CLAIMS INFORMATION. Pursuant to Section 11752.6 of the California Insurance <br />Code. upon written request, you are entitled to information relating to loss experience, claims. class- <br />ification assignments. and policy contracts, as well as rating plans, rating systems. manual rules, or <br />other information impacting your premium that is maintained in the records of the Workers' Compen- <br />sation Insurance Rating Sureau of California ("WCIRS"), a rating organization licensed by the California <br />Insurance Commissioner. Requests for policyholder information should be forwarded to: WCIRS. <br />525 Market Street, Suite 800, San Francisco, California 94105-2716, Attention: Custodian of <br />Records. The Custodian of Records can be reached by telephone at 1-888-229-2472, and the fax <br />number is 415-778-7272. <br /> <br />Pursuant to Sections 3761 and 3762 of the California Labor Code. you are also entitled to receive <br />information in our claim files that affects your premium. <br /> <br />2. POLICYHOLDER OMBUDSMAN. Pursuant to California Insurance Code Sections 11752.6 (g) and <br />(h) (1), a policyholder ombudsman is available at the WCIRS to assist you in obtaining and evaluating <br />the information referenced above. The ombudsman may advise you on any dispute with us, the WCIRS, <br />or on an appeal to the Insurance Commissioner pursuant to Section 11737 of the Insurance Code. <br />The address of the policyholder ombudsman is WCIRS, 525 Market Street, Suite 800, San Francisco, <br />California 94105-2716. Attention: Policyholder Ombudsman. The policyholder ombudsman can be <br />reached by telephone at 415-777-0777 and by fax at 415-778-7007. <br /> <br />3. CALIFORNIA DEPARTMENT OF INSURANCE. Information and assistance on policy questions can <br />be obtained from the Department of Insurance Consumer HOTLINE, 1-800-927-HELP (4357). <br /> <br />- <br /> <br />4. STATISTICAL REPORTING. For claims covered under this policy, we will estimate the ultimate <br />cost of unsettled claims for statistical purposes eighteen months after the policy becomes effective <br />and will report those estimates to the WCIRS no later than twenty months after the effective date <br />of the policy. The cost of any settled claims will also be reported at that time. At twelve-month <br />intervals thereafter, we will update and report to the WCIRS the estimated cost of any unsettled <br />claims and the actual final cost of any claims settled in the interim. The amounts we report will be <br />used by the WCIRS to compute your experience modification if you are eligible for experience <br />rating. <br /> <br />5. DIVIDEND CALCULATION. If this is a participating policy (a policy on which a dividend may be <br />paid), upon payment or non-payment of a dividend, we shall provide a written explanation to you <br />that sets forth the basis of the dividend calculation. The explanation will be in clear, understandable <br />language and will express the dividend as a dollar amount and as a percentage of the earned premium <br />for the policy year on which the dividend is calculated. <br /> <br />selF 10610 (Rev. 04-07) <br />