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POLICYHOLDER NOTICE <br />Your Right to Rating and Dividend Information <br />Page 3 of 3 <br />POLICY NO. 9048876-15 <br />NR SP <br />C. California Department of Insurance - Appeals to the Insurance Commissioner. If, after you <br />follow the appropriate dispute resolution process described above, we or the WCIRB decline to review your <br />request, if you are dissatisfied with the decision upon review, or if we or the WCIRB fail to grant or reject your <br />request or issue a decision upon review, you may appeal to the insurance commissioner pursuant to CIC <br />Sections 11737, 11752.6, 11753.1 and Title 10, California Code of Regulations, Section 2509.40 at seq. You <br />must file your appeal within 30 days after we or the WCIRB send you the notice rejecting review of your <br />request for reconsideration or the decision upon your request for reconsideration. If no written decision <br />regarding your request is sent, your appeal must be filed within 120 days after you sent your request for <br />reconsideration to us or to the WCIRB. The filing address for all appeals to the insurance commissioner is: <br />Administrative Hearing Bureau <br />California Department of Insurance <br />45 Fremont Street, 22nd Floor <br />San Francisco, California 94105 <br />You have the right to a hearing before the insurance commissioner, and our action, or the action of the <br />WCIRB, may be affirmed, modified, or reversed. <br />III. Resources Available to You in Obtaining Information and Pursuing Disputes <br />A. Policyholder Ombudsman. Pursuant to California Insurance Code Section 11752.6, a policyholder <br />ombudsman is available at the WCIRB to assist you in obtaining and evaluating the rating, policy, and <br />claims information referenced in I.A. and I.B., above. The ombudsman may advise you on any dispute <br />with us, the WCIRB, or on an appeal to the insurance commissioner pursuant to Section 11737 of the <br />Insurance Code. The address of the policyholder ombudsman is WCIRB, 1221 Broadway, Suite 900, <br />Oakland, California 94612, Attention: Policyholder Ombudsman. The policyholder ombudsman <br />can be reached by telephone at 415-778-7159 and by fax at 415-371-5288. <br />B. California Department of Insurance - Information and Assistance. Information and assistance <br />on policy questions can be obtained from the Department of Insurance Consumer HOTLINE, 1 -800 -927 - <br />HELP (4357) or http:/Iwww.insurance.ca.gov. For questions and correspondence regarding appeals to the <br />Administrative Hearing Bureau, see the contact information in paragraph II.C. <br />This notice does not change the policy to which it is attached. <br />a Guev <br />P� GGp�pd <br />.SCIF 1RRM R IR>V. U -M <br />