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QPMJDZIPMEFS!OPUJDF <br />ZPVS!SJHIU!UP!SBUJOH!BOE!EJWJEFOE!JOGPSNBUJPO <br />J/Jogpsnbujpo!Bwbjmbcmf!up!Zpv <br />B/Jogpsnbujpo!Bwbjmbcmf!gspn!Vt!.Ibsugpse!Dbtvbmuz!Jotvsbodf!Dpnqboz <br />1General estions regarding yor policy sold e directed to zpvs!Ibsugpse!Bhfou!ps <br />Ibsugpse!Dbtvbmuz!Jotvsbodf!Dpnqboz <br />4711!Xjtfnbo!Cmwe <br />Tbo!Boupojp-!UY!89362 <br />Ufmfqipof;)988*!398.2427 <br />bhfodz/tfswjdftAuifibsugpse/dpn <br />xxx/uifibsugpse/dpn <br />2EjwjefoeDbmdvmbujpo/Iftisisaparticipatingpolicyapolicyonwicadiidendmayepaid,pon <br />paymentornon-paymentofadiidend,wesallproideawritteneplanationtoyotatsetsfortte <br />asisoftediidendcalclation.Teeplanationwilleinclear,nderstandalelangageandwill <br />epresstediidendasadollaramontandasapercentageofteearnedpremimfortepolicyyear <br />on wic te diidend is calclated. <br />3DmbjntJogpsnbujpo/PrsanttoSections361and362ofteCaliforniaLaorCode,yoareentitled <br />toreceieinformationinorclaimfilestataffectsyorpremim.Copiesofdocmentswillesppliedat <br />yor epense dring reasonale siness ors. <br />Forclaimscoeredndertispolicy,wewillestimateteltimatecostofnsettledclaimsforstatistical <br />prposeseigteenmontsaftertepolicyecomeseffectieandwillreporttoseestimatestote <br />WorersCompensationInsranceRatingBreaofCaliforniaWCIRBnolatertantwentymontsafter <br />tepolicyecomeseffectie.Tecostofanysettledclaimswillalsoereportedattattime.Attwele- <br />montinteralstereafter,wewillpdateandreporttoteWCIRBteestimatedcostofanynsettled <br />claimsandteactalfinalcostofanyclaimssettledinteinterim.Teamontswereportwillesedy <br />te WCIRB to compte yor eperience modification if yo are eligile for eperience rating. <br />C/Jogpsnbujpo!Bwbjmbcmf!gspn!uif!Xpslfst(!Dpnqfotbujpo!Jotvsbodf!Sbujoh!Cvsfbv!pg!Dbmjgpsojb <br />1TeWCIRBisalicensedratingorganiationandteCaliforniaInsranceCommissionersdesignated <br />statisticalagent.Assc,teWCIRBisresponsileforadministeringte CaliforniaWorkers' <br />CompensationUniformStatisticalReportingPlan—1995SRPandte CaliforniaWorkers' <br />CompensationExperienceRatingPlan—1995ERP.WCIRBcontactinformationisWCIRB,One <br />MontgomeryStreet,Site400,SanFrancisco,CA94104,AttnCstomerSerice888.229.242pone <br />41.8.22faandcstomersericewcir.comemail.TereglationscontainedinteSRP <br />and ERP are aailale for plic iewing trog te WCIRBs wesite atwcir.com. <br />2QpmjdzipmefsJogpsnbujpo/PrsanttoCaliforniaInsranceCodeCICSection112.6,ponwritten <br />reest,yoareentitledtoinformationrelatingtolosseperience,claims,classificationassignments,and <br />policycontractsaswellasratingplans,ratingsystems,manalrles,oroterinformationimpactingyor <br />premimtatismaintainedinterecordsofteWCIRB.ComplaintsandReestsforActionreesting <br />policyolderinformationsoldeforwardedtoWCIRB,OneMontgomeryStreet,Site400,San <br />Francisco,CA94104,AttnCstodianofRecords.TeCstodianofRecordscanereacedat <br />41..0 pone and 41.8.22 fa. <br />3FyqfsjfodfSbujohGpsn/EaceperienceratedrismayreceieasinglecopyofitscrrentEperience <br />RatingForm/WorseetfreeofcargeycompletingaPolicyolderEperienceRatingWorseet <br />ReestFormonteWCIRBswesiteatwcir.com/rateseet.TeEperienceRatingForm/Worseet <br />willincldeaLoss-FreeRating,wicisteeperiencemodificationtatwoldaeeencalclatedif <br />Gpsn!QO!15!::!12!K!)17036*Printed in .S.A.Qbhf2!pg4 <br />Qspdftt!Ebuf; 11/04/2Qpmjdz!Fyqjsbujpo!Ebuf;11/04/26 <br /> <br />