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POLICYHOLDER NOTICE Page 1 of 3 <br />YOUR RIGHT TO RATING AND DIVIDEND INFORMATION <br />PN 04 99 01 F (Ed. 03-15) <br />FRIENDS OF SANTA ANA ZOO <br />1801 E CHESTNUT AVE <br />SANTA ANA, CALIF 92701 <br />POLICY NO. 9048876-15 <br />NR SP <br />Information Available to You. <br />A. Information Available from Us -State Compensation Insurance Fund <br />(1) General questions regarding your policy should be directed to: <br />State Fund, Customer Service Center <br />1020 Vaquero Circle <br />Vacaville, CA 95688 <br />Telephone: 888-782-8338 <br />(2) Dividend Calculation. If this is a participating policy (a policy on which a dividend may be paid), upon <br />payment or non-payment of a dividend, we shall provide a written explanation to you that sets forth the <br />basis of the dividend calculation. The explanation will be in clear, understandable language and will <br />express the dividend as a dollar amount and as a percentage of the earned premium for the policy year <br />on which the dividend is calculated. <br />(3) ClaimsInformatioii: Pursuant`to Sections 3761 and 3762 or""the California Labor Code, `you are <br />entitled to receive information in our claim files that affects your premium. Copies of documents will be <br />supplied at your expense during reasonable business hours. <br />For claims covered under this policy, we will estimate the ultimate cost of unsettled claims for statistical <br />purposes eighteen months after the policy becomes effective and will report those estimates to the Workers' <br />Compensation Insurance Rating Bureau of California (WCIRB) no later than twenty months after the <br />policy becomes effective. The cost of any settled claims will also be reported at that time. At twelve-month <br />intervals thereafter, we will update and report to the WCIRB the estimated cost of any unsettled claims <br />and the actual final cost of any claims settled in the interim.The amounts we report will be used by the <br />WCIRB to compute your experience modification if you are eligible for experience rating. <br />B. Information Available from the Workers' Compensation Insurance Rating Bureau of <br />California <br />(1) The WCIRB is a licensed rating organization and the California Insurance Commissioner's designated <br />statistical agent. As such, the WCIRB is responsible for administering the California Workers' Compensation <br />Uniform Statistical Reporting Plan-4995(USRP) and the California Workers'Compensation Experience <br />Rating Plan— I 995(ERP). Contact information for the WCIRB is: WCIRB, 1221 Broadway, Suite 900, <br />Oakland, California 94612, Attention: Customer Service. You may also contact WCIRB Customer <br />Service at 1.888-229-2472, by fax at 415-778-7272, or via the Internet at the WCIRB's website: <br />http:/Iwww.wcirb.com. The regulations contained in the USRP and the ERP are available for PO4f"ic,� <br />viewing through the WCIRB's website. <br />(2) Policyholder Information. Pursuant to California Insurance Code (CIC) Secti52.6, upon w' n <br />request, you are entitled to information relating to loss experience, claims, classification assign . and <br />policy contracts as well as rating plans, rating systems, manual rules, or other information ' fir <br />premium that is maintained in the records of the WCIRB. Complaints and Requests f i9 <br />policyholder information should be forwarded to: WCIRB, 1221 Broadway, Suit �� P <br />California 94612, Attention: Custodian of Records. The Custodian of Record can be �g �d by <br />telephone at 415-777-0777 and by fax at 415-778.7272. <br />0 <br />