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POLICYHOLDER NOTICE
<br />Your Right to Rating and Dividend Information
<br />Page 2 of 3
<br />POLICY NO. 9102788-15
<br />NR SC
<br />(3) Experience Rating Form. Each experience rated risk may receive a single copy of its current
<br />Experience Rating Form free of charge by completing a Policyholder Rate Sheet Request Form on the
<br />WCIRB's website at http://wcirb.com/ratesheet, The Experience Rating Form will include a Loss -Free
<br />Rating, which is the experience modification that would have been calculated if $0 (zero) actual losses were
<br />incurred during the experience period. This hypothetical rating calculation is provided for informational
<br />purposes only,
<br />Ill. Dispute Process
<br />You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1.
<br />A. Our Dispute Resolution Process.
<br />You may request in writing that we reconsider a change in a classification assignment that results in an
<br />increased premium. You may also request, in writing, that we review the manner in which our rating system
<br />has been applied in connection with the insurance afforded or offered you. Written requests that we
<br />reconsider or review our actions should be forwarded to: State Compensation Insurance Fund, Attention:
<br />Manager, Customer Assistance Program, 5680 Owens Drive, Pleasanton, CA 94588 or call us at
<br />925-460.6530 or fax us at 925-460.6633.
<br />B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission
<br />to act of the WCIRB, you may request, in writing, that the WCIRB reconsider its decision, action, or omission
<br />to act. You may also request, in writing, that the WCIRB review the manner in which its rating system has
<br />been applied in connection with the insurance afforded or offered you. For requests related to classification
<br />disputes, the reporting of experience, or coverage issues, your initial request for review must be received
<br />by the WCIRB within 12 months after the expiration date of the policy to which the request for review
<br />pertains, except if the request involves -the application of the Revision of Losses rule. For requests related
<br />to your experience modificaton, your initial request for review must be received by the WCIRB within 6 months
<br />after the issuance, or 12 months after the expiration date, of the experience modification to which the request
<br />for review pertains, whichever is later, except if the request for review involves the application of the
<br />Revision of Losses rule. If the request involves the Revision of Losses rule, the time to state your appeal
<br />may be longer. (See Section VI, Rule 14 of the ERP).
<br />You may commence the review process by sending the WCIRB a written Inquiry. Written Inquiries should be
<br />sent to: WCIRB, 1221 Broadway, Suite 900, Oakland, California94612, Attention: Customer Service.
<br />Customer Service can be reached by telephone at 1-888-229-2472, and by fax at 415-778.7272.
<br />If you are dissatisfied with the WCIRB's decision upon an Inquiry, or if the WCIRB fails to respond within
<br />90 days after receipt of the Inquiry, you may pursue the subject of the inquiry by sending the WCIRB a
<br />written Complaint and Request for Action. After you send your Complaint and Request for Action, the WCIRB
<br />has 30 days to send you written notice indicating whether or not your written request will be reviewed.
<br />If the WCIRB agrees to review your request, it must conduct the review and issue a decision granting or
<br />rejecting your request within 60 days after sending you the written notice granting review. If the WCIRB
<br />declines to review your request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to
<br />grant or reject your request or issue a decision upon review, you, may appeal to the insurance commissioner
<br />as described in paragraph ILC., below. Written Complaints and Requests for Action should be forwarded to:
<br />WCIRB, 1221 Broadway, Suite 900, Oakland, California 94612, Attention: Complaints and Reconsiderations.
<br />The WCIRB's telephone number is 1-888-229-2472, and the fax number is 415-371-5204.
<br />5CIF 10610 8 (Rev. 04.15)
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