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WORKERS' COMPENSATION DISCLOSURE FORM IMPORTANT NOTICE TO POLICYHOLDERS 1. NOTICE OF CHANGE IN RATE BY CLASSIFICATION If you desire information whenever there is a change in your workers' compensation insurance rate by classification, you must request such information from your insurer. This request for information must be in writing. 2. NOTICE OF POLICYHOLDER'S RIGHT TO APPEAL CLASSIFICATION Your insurer can charge and collect any additional amount of money not included in the initial premium charged as a result of job misclassification. If you have any questions regarding the employee classification assigned to calculate your workers' compensation insurance premium, you need to direct your questions to your insurer or the insurer's authorized representative within either thirty (30) days after the anniversary date of the policy or the date of receipt by you of notice of a change in job classification. Within thirty (30) days after receipt of your request for information, your insurer or the insurer's authorized representative must explain to you why a particular employee classification was used. If you disagree with your insurer or the insurer's authorized representative on the employee classification assignment, you may appeal to the Workers' Compensation Classification Appeal Board by filing written notice with said board within thirty (30) days after you have exhausted all appeal review procedures provided by the insurer. Your request should be sent to the Secretary of the Colorado Workers' Compensation Classification Appeals Board, Michael Craddock, c/o National Council on Compensation Insurance, 901 Peninsula Corporate Circle, Boca Raton, FL 33487. Written instructions for your appearance before the Colorado Workers' Compensation Classification Appeals Board will be furnished by the Secretary of the board. The board will render a decision as to whether a misclassification has occurred. A decision by the board is final and not subject to appeal unless you, the insurer or Pinnacol Assurance provides written notice of appeal within thirty (30) days after the board's decision to the office of the Commissioner of Insurance, 1560 Broadway, Suite 850, Denver, CO 80202. The Commissioner shall review any decision of the board properly appealed. 3. NOTICE OF AVAILABILITY OF MEDICAL CASE MANAGEMENT SERVICES On appropriate cases, staff Health Service Representatives (R.N.'s) or outside vendors are assigned for medical case management to insure quality medical care and rehabilitation at a reasonable cost. The use includes, but is not limited to, coordinating with qualified medical providers, monitoring the rehabilitation process and working with employers to return the injured party to their regular or a modified position. Form WC 66 00 89 B Printed in U.S.A. ew cF RAMwagementDMsian Jy/\'x REVIEWED & APPROVED BY.- V"° --� Risk janagement Analyst