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COMPLAINT NOTICE: <br /> DISPUTE RESOLUTION SERVICES <br /> NCCI'S DISPUTE RESOLUTION PROCESS DOES NOT APPLY TO WORKERS COMPENSATION CLAIMS. <br /> For workers compensation claim disputes, see "CLAIM COMPLAINT" below. For issues related to a violation of <br /> law related to your policy,see "VIOLATIONS OF LAW" below. <br /> Important Note: The dispute resolution services provided through the Dispute Resolution Process (Process) of the <br /> National Council on Compensation Insurance (NCCI) are voluntary. The Process is not an administrative remedy that <br /> must be exhausted before you pursue relief in court. Using the Process does not prevent you or the carrier that issued <br /> the policy from pursuing any available legal remedies at any time. <br /> NCCI can assist in the resolution of a dispute regarding your policy that is related to any of the following matters: <br /> o The application or interpretation of rules contained in the various NCCI manuals (including, but not limited to, <br /> classification codes and experience rating modifications) <br /> o Rating programs <br /> o Endorsements <br /> o Forms <br /> Contact the carrier that issued the policy and attempt to resolve the dispute directly. If you and the carrier cannot agree, <br /> then contact NCCI to ask for assistance. NCCI's Basic Manua! rule, Dispute Resolution Process, addresses disputes. <br /> You may obtain dispute resolution services only after you have made a reasonable attempt to first resolve the dispute <br /> directly with the carrier and after you have paid any undisputed premium due to the carrier. <br /> Send your request for assistance by mail to NCCI, Dispute Resolution Services, 901 Peninsula Corporate Circle, Boca <br /> Raton, FL 33487-1362; or by fax to 561-893-5043; or by email to disputeresolution@ncci.com. <br /> THIS NOTICE OF THE DISPUTE RESOLUTION PROCESS IS FOR INFORMATION ONLY AND DOES NOT BECOME <br /> A PART,TERM, OR CONDITION OF THIS POLICY. <br /> VIOLATIONS OF LAW: <br /> If you believe there has been a violation of law related to your policy, file a complaint with the Texas Department of <br /> Insurance: <br /> Phone: 1-800-252-3439 Online:tdi.texas.gov <br /> Email: ConsumerProtection@tdi.texas.gov Mail: MC CO-CP, PO Box 12030, Austin, TX 78711-2030 <br /> CLAIM COMPLAINT: <br /> If there is a workers compensation claim complaint involving one of your employees, then contact the Texas Department <br /> of Insurance - Division of Workers' Compensation, Compliance and Investigations by mail to MC: Cl, PO Box 12050, <br /> Austin, TX 78711-2050; or by fax to 512-490-1030; or by email to DWCCOMPLAINTS@tdi.texas.gov. <br /> THIS NOTICE IS FOR INFORMATION ONLY AND DOES NOT BECOME A PART, TERM, OR CONDITION OF THIS <br /> POLICY. <br /> Form WC 42 03 01 L Printed in U.S.A. Page 3 of 3 <br />