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<br />POLICY NO. 1801464-07
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<br />6. DISPUTING OUR ACTIONS. Pursuant to Insurance Code Section 1 1753.1 (bl. you may request,
<br />in writing, that we reconsider a change in a classification assignment that results in an increased pre-
<br />mium. You may also request, in writing, that we review the manner in which our rating system has
<br />been applied in connection with the insurance afforded or offered you pursuant to Insurance Code
<br />Section 11737 (fl. Written requests that we reconsider or review our actions should be forwarded
<br />to: State Compensation Insurance Fund, Attention: Manager, Customer Assistance Program,
<br />5860 Owens Drive, Pleasanton, CA 94568, Telephone: (925) 460-6530, Fax: (925) 460-6633.
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<br />7. DISPUTING THE ACTIONS OF THE WCIRS. If you have been aggrieved by any decision, action,
<br />or omission to act of the WCIR8, you may request, in writing, that the WCIRS reconsider its decision,
<br />action, or omission to act pursuant to Insurance Code Section 11753.1 (a). You may also request. in
<br />writing, that the WCIRS review the manner in which its rating system has been applied in connection
<br />with the insurance afforded or offered you pursuant to Insurance Code Section 11737 (f). Written
<br />requests for reconsideration or requests for review regarding the actions of the WCIRS should be
<br />forwarded to: WCIRS, 525 Market Street, Suite 800, San Francisco, California 94105-2716,
<br />Attention: Complaints and Reconsiderations. The WCIRS's telephone number is 1-888-229-2472, and
<br />the fax number is 415-371-5204.
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<br />8. APPEAL TO THE INSURANCE COMMISSIONER. After you send your written request for policyholder
<br />information, reconsideration, or review of the manner in which the rating system has been applied in
<br />connection with the insurance afforded or offered you, we, or the WCIRS, have 30 days to provide
<br />you written notice indicating whether or not your written request will be reviewed. If we, or the
<br />WCIRS, agree to review your request, we, or the WCIRS, must conduct the review and issue a decision
<br />granting or rejecting your request within 60 days after sending you the written notice granting review.
<br />If we, or the WCIRS, decline to review your request. or if you are dissatisfied with the decision upon
<br />review, or if your request is rejected or not acted upon, you may appeal to the Insurance Commissioner
<br />pursuant to the provisions of Insurance Code Sections 11752.6(cl. 11753.1 (a) and (b), or 11737(f) and
<br />Title 10, California Code of Regulations, Section 2509.40 et seq. You must make your appeal within 30
<br />days after we, or the WCIRS, send you the notice denying review of your request or the decision upon
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<br />review. If no written decision regarding your request for policyholder information, reconsideration, or
<br />review is sent. your appeal must be filed within 120 days after you sent your request to us, or the
<br />WCIRS. The filing address for all appeals to the Commissioner is:
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<br />Administrative Hearing Sureau
<br />California Department of Insurance
<br />45 Fremont Street. 22nd Floor
<br />San Francisco, California 94105
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<br />The Insurance Commissioner will hold a hearing upon your appeal and may either affirm, modify, or
<br />reverse our action or that of the WCIRS.
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<br />This notice does not change the policy to which it is attached.
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