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COMPLAINT NOTICE: <br />DISPUTE RESOLUTION SERVICES <br />NCCI'S DISPUTE RESOLUTION PROCESS DOES NOT APPLY TO WORKERS COMPENSATION CLAIMS. <br />For workers compensation claim disputes, see "CLAIM COMPLAINT" below. For issues related to a violation of <br />law related to your policy, see "VIOLATIONS OF LAW" below. <br />Important Note: T❑e disp❑te resolLtion ser[ces prouded tL]roEg❑ t❑e Disp❑te Resol tion Process iProcess❑of t❑e <br />❑ational CoAcil on Compensation Insisance 1111CCI11are voluntary. T❑e Process is not an administratie remedy t❑at <br />m❑st e e2aC:sted ❑efore yo❑ plirs❑e relief in coErt. ❑sing to Process does not preent yo❑ or to carrier t❑at issed <br />t❑e policy from plirsEJng any aeilade legal remedies at any time. <br />[]CC[ can assist in t'e resol tion of a disp to regarding yo-r policy t❑at is related to any of t❑e following matters[] <br />o T❑e application or interpretation of ryes contained in to CarioC:8 ❑CCI manels CChcl❑ding, ❑A not limited to, <br />classification codes and e-perience rating modifications❑ <br />o Rating programs <br />o Endorsements <br />o Forms <br />Contact to carrier ti❑at iss❑ed t❑e policy and attempt to resole to disp❑te directly. If yo❑ and tie carrier cannot agree, <br />t❑en contact ❑CCI to as❑for assistance. ❑CCIs Basic Manual rAe, Disp❑te Resol tion Process, addresses disp tes. <br />Yo❑ may oEtain disp❑te resolEtion serdces only after yo❑ ❑ae made a reasona:Ae attempt to first resole t❑e disp❑te <br />directly wit❑t❑e carrier and after yo❑ ❑ae paid any odispEted premilin de to tie carrier. <br />Send yos re❑❑est for assistance ❑y mail to ❑CCI, Disp❑te Resol tion Serdces, 901 Penins-la Corporate Circle, Boca <br />Raton, FL 3348D-1362or ❑y fa❑to ❑61-893-E043or ❑y email to disp teresolEtion❑ ncci.com. <br />THIS NOTICE OF THE DISPUTE RESOLUTION PROCESS IS FOR INFORMATION ONLY AND DOES NOT BECOME <br />A PART, TERM, OR CONDITION OF THIS POLICY. <br />VIOLATIONS OF LAW: <br />If yo❑ ❑eliee t❑ere ❑as ❑een a Jolation of law related to yo-r policy, file a complaint wit[] t❑e Tees Department of <br />Instance❑ <br />Phone: 1-800-2E2-3439 Online: tdi.tees.go❑ <br />Email: Cons linerProtection❑ tdi.teEas.go❑ Mail: MC CO-CP, PO Bo❑12030, AC:8tin, TO ❑81111-2030 <br />CLAIM COMPLAINT: <br />If t ere is a worers compensation claim complaint inolrng one of yo-r employees, ten contact t❑e Tees Department <br />of Ins-rance - Di:jsion of Worers❑Compensation, Compliance and Inestigations ❑y mail to MC❑CI, PO Bo-1 1201:0, <br />Aetin, T❑ ❑81111-20EOor ❑y fa❑to 1112-490-1030 or -_y email to DWCCOMPLAI❑TS❑ tdi.tees.go❑ <br />THIS NOTICE IS FOR INFORMATION ONLY AND DOES NOT BECOME A PART, TERM, OR CONDITION OF THIS <br />POLICY. <br />Form WC 42 03 01 L Printed in O.S.A. Page 3 of 3 <br />