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PN 04 99 01 H ( Ed . 05 -20 ) POLICYHOLDER NOTICE YOUR RIGHT TO RATING AND DIVIDEND INFORMATION I . Information Available to You A . Information Available from Us – Wesco Insurance Company ( 1 ) General questions regarding your policy should be directed to : Wesco Insurance Company 800 Superior Ave . E . , 21St Floor Cleveland , OH 44114 Telephone : 877-528 -7878 (2) Dividend Calculation . If this is a participating policy ( a policy on which a dividend may be paid ) , upon payment or non - payment of a dividend , we shall provide a written explanation to you that sets forth the basis of the dividend calculation . The explanation will be in clear, understandable language and will express the dividend as a dollar amount and as a percentage of the earned premium for the policy year on which the dividend is calculated . (3) Claims Information . Pursuant to Sections 3761 and 3762 of the California Labor Code , you are entitled to receive information in our claim files that affects your premium . Copies of documents will be supplied at your expense during reasonable business hours . For claims covered under this policy , we will estimate the ultimate cost of unsettled claims for statistical purposes eighteen months after the policy becomes effective and will report those estimates to the Workers ' Compensation Insurance Rating Bureau of California (WCIRB ) no later than twenty months after the policy becomes effective . The cost of any settled claims will also be reported at that time . At twelve-month intervals thereafter, we will update and report to the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim . The amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience rating . B . Information Available from the Workers ' Compensation Insurance Rating Bureau of California ( 1 ) The WCIRB is a licensed rating organization and the California Insurance Commissioner's designated statistical agent. As such , the WCIRB is responsible for administering the California Workers ' Compensation Uniform Statistical Reporting Plan- 1995 ( USRP ) and the California Workers ' Compensation Experience Rating Plan- 1995 ( ERP ) . WCIRB contact information is : WCIRB , 1221 Broadway, Suite 900 , Oakland , CA 94612 , Attn : Customer Service ; 888 . 229 . 2472 (phone) ; 415 . 778 . 7272 (fax) ; and customerserviceawcirb . com (email ) . The regulations contained in the USRP and ERP are available for public viewing through the WCIRB Is website at wcirb . com . ( 2 ) Policyholder Information . Pursuant to California Insurance Code (CIC ) Section 11752 . 6 , upon written request, you are entitled to information relating to loss experience , claims , classification assignments , and policy contracts as well as rating plans , rating systems , manual rules , or other information impacting your premium that is maintained in the records of the WCIRB . Complaints and Requests for Action requesting policyholder information should be forwarded to : WCIRB , 1221 Broadway , Suite 900 , Oakland , CA 94612 , Attn : Custodian of Records . The Custodian of Records can be reached at 415 . 777 . 0777 (phone) and 415 . 778 . 7272 (fax) . ( 3 ) Experience Rating Form . Each experience rated risk may receive a single copy of its current Experience Rating Form/Worksheet free of charge by completing a Policyholder Experience Rating Worksheet Request Form on the WCIRB ' s website at wcirb . com/ratesheet. The Experience Rating Form/Worksheet will include a Loss- Free Rating , which is the experience modification that would have been calculated if $0 (zero) actual losses were incurred during the experience period . This hypothetical rating calculation is provided for informational purposes only . II . Dispute Process You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753 . 1 . A . Our Dispute Resolution Process . If you are aggrieved by our decision adopting a change in a classification assignment that results in increased premium , or by the application of our rating system to your workers ' compensation insurance , you may dispute these matters with us . If you are dissatisfied with the outcome of the initial dispute with us , you may send us a written Complaint and Request for Action as outlined below . You may send us a written Complaint and Request for Action requesting that we reconsider a change in a classification assignment that results in an increased premium and/or requesting that we review the manner in which our rating system has been applied in connection with the insurance afforded or offered you . Written Complaints and Requests for Action should be forwarded to : Wesco Insurance Company Consumer Relations , 800 Superior Ave . E . , 21st Floor, Cleveland , OH 44114 . PN 04 99 01 H 1 of 2 ( Ed . 05 -20)