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$0 (zero) actual losses were incurred during the experience period. This hypothetical rating calculation is
<br /> provided for informational purposes only.
<br /> II. 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 send us a written Complaint and Request for Action requesting that we reconsider a change in a
<br /> classification assignment that results in an increased premium and/or requesting that we review the manner in
<br /> which our rating system has been applied in connection with the insurance afforded or offered you. Written
<br /> Complaints and Requests for Action should be forwarded to=
<br /> Hartford Casualty Insurance Company
<br /> One Pointe Drive, Suite 200, Brea, CA 92821; Telephone(800)451-6944; Fax(860) 7234289.
<br /> After you send your Complaint and Request for Action, we have 30 days to send you a written notice
<br /> indicating whether your written request will be reviewed. If we agree to review your request, we must conduct
<br /> the review and issue a decision granting or rejecting your request within 60 days after sending you the written
<br /> notice granting review. If we decline to review your request, if you are dissatisfied with the decision upon
<br /> review, or if we fail to grant or reject your request or issue a decision upon review, you may appeal to the
<br /> Insurance Commissioner as described in paragraph II.C., below.
<br /> B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission to act
<br /> of the WCIRB, you may request, in writing, that the WCIRB reconsider its decision, action, or omission to act.
<br /> You may also request, in writing, that the WCIRB review the manner in which its rating system has been
<br /> 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 by
<br /> the WCIRB within 12 months after the expiration date of the policy to which the request for review pertains,
<br /> except if the request involves the application of the Revision of Losses rule. For requests related to your
<br /> experience modification, your initial request for review must be received by the WCIRB within 6 months after
<br /> the issuance, or 12 months after the expiration date, of the experience modification to which the request for
<br /> review pertains, whichever is later, except if the request for review involves the application of the Revision of
<br /> Losses rule. If the request involves the Revision of Losses rule, the time to state your appeal may be longer.
<br /> (See Section VI, Rule 7 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, One Montgomery Street, Suite 400, San Francisco, CA 94104, Attn: Customer Service.
<br /> Customer Service can be reached at 888.229.2472 (phone), 415.778.7272 (fax) and
<br /> customerservice@wcirb.com (email).
<br /> If you are dissatisfied with the WCIRB's decision upon an Inquiry, or if the WCIRB fails to respond within 90
<br /> days after receipt of the Inquiry, you may pursue the subject of the Inquiry by sending the WCIRB a written
<br /> Complaint and Request for Action. After you send your Complaint and Request for Action, the WCIRB has 30
<br /> days to send you written notice indicating whether your written request will be reviewed. If the WCIRB agrees
<br /> to review your request, it must conduct the review and issue a decision granting or rejecting your request
<br /> within 60 days after sending you the written notice granting review. If the WCIRB declines to review your
<br /> request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to grant or reject your
<br /> request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in
<br /> paragraph II.C., below. Written Complaints and Requests for Action should be forwarded to: WCIRB, One
<br /> Montgomery Street, Suite 400, San Francisco, CA 94104, Attn: Complaints and Reconsideration. The
<br /> WCIRB's contact information is 888.229.2472 (phone), 415.371.5204 (fax) and
<br /> customerservice@wcirb.com (email).
<br /> C. California Department of Insurance - Appeals to the Insurance Commissioner. After you follow the
<br /> appropriate dispute resolution process described above, if (1) we or the WCIRB decline to review your
<br /> request, (2) you are dissatisfied with the decision upon review, or (3) we or the WCIRB fail to grant or reject
<br /> your request or issue a decision upon review, you may appeal to the Insurance Commissioner pursuant to
<br /> CIC Sections 11737, 11752.6, 11753.1 and Title 10, California Code of Regulations, Section 2509.40 et seq.
<br /> You must file your appeal within 30 days after we or the WCIRB send you the notice rejecting review of your
<br /> Complaint and Request for Action or the decision upon your Complaint and Request for Action. If no written
<br /> decision regarding your Complaint and Request for Action is sent, your appeal must be filed within 120 days
<br /> after you sent your Complaint and Request for Action to us or to the WCIRB. The filing address for all appeals
<br /> to the Insurance Commissioner is:
<br /> Form PN 04 99 01 J (06/25) Printed in U.S.A. Page 2 of 3
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