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Administratie earing Brea <br />California Department of Insrance <br />1901 arrison Street, 3rd Floor Mailroom <br />Oaland, CA 94612 <br />41.38.4243 <br />YoaeterigttoaearingeforeteInsranceCommissioner,andoraction,orteactionofte <br />WCIRB, may e affirmed, modified or reersed. <br />JJJ/Sftpvsdft!Bwbjmbcmf!up!Zpv!jo!Pcubjojoh!Jogpsnbujpo!boe!Qvstvjoh!Ejtqvuft <br />B/QpmjdzipmefsPncvetnbo/PrsanttoCaliforniaInsranceCodeSection112.6,apolicyolder <br />omdsmanisaailaleatteWCIRBtoassistyoinotainingandealatingterating,policy,andclaims <br />informationreferencedinI.A.andI.B.,aoe.Teomdsmanmayadiseyoonanydisptewits,te <br />WCIRB,oronanappealtoteInsranceCommissionerprsanttoSection113ofteInsranceCode. <br />TeaddressoftepolicyolderomdsmanisWCIRB,OneMontgomeryStreet,Site400,SanFrancisco, <br />CA94104,AttnPolicyolderOmdsman.Tepolicyolderomdsmancanereacedat41.8.19 <br />pone, 41.31.288 fa andomdsmanwcir.com email. <br />C/DbmjgpsojbEfqbsunfoupgJotvsbodf.JogpsnbujpoboeBttjtubodf/Informationandassistanceonpolicy <br />estionscaneotainedfromteDepartmentofInsranceConsmerOTLIE,800.92.ELP43or <br />insrance.ca.go.ForestionsandcorrespondenceregardingappealstoteAdministratieearing <br />Brea, see te contact information in paragrap II.C. <br />Tis notice does not cange te policy to wic it is attaced. <br />Gpsn!QO!15!::!12!K!)17036*Printed in .S.A.Qbhf4!pg4 <br /> <br />