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HomeMy WebLinkAboutA6374 - MEASURE J AGREED UPON PROCEDURES WITH MARYANOV, MADSEN, GORDON & CAMPBELL CONTRACT ABSTRACT Contract Company Name: Maryanov, Madsen, Gordon & Campbell Company Contact: Steven Erickson Summary of Services: Measure J Agreed Upon Procedures Contract Price: NTE $2,500 Funding Source: 260-1396-42302 Contract Term: FY 2018/2019 Reporting Contract Administration Lead Department: Finance Department Contract Administrator: Ariana Muniz Contract Approvals Council/ Community Redevelopment Agency Approval Date: 12/10/2019 by Nancy Pauley, Finance Director Item No,/ Resolution Number: Agreement No: A6374 Contract Compliance Exhibits: Signatures: Insurance: Bonds Contract prepared by: Submitted on: 12/10/2019 By: Ariana Muniz G. R_ JDOb N,` AM,,Fb t MAJ�_ YA`� 'OJV KADSEN, 101 JbL �' ' Certified Public Accountants A p r 0 f e.S s is o n a I C-o r p o r a I i a n December 10,2019 Wrng4 am Steven T.Erickson.dl!� Nancy Pauley Director of Finance MAN AGING PARTNER City of Palm,Springs Don Kiesft'CPA UWE Tahquitz Canyon Way PARTNER Palm Springis,'CAV=-6969 StephenDawson,CPA PARTNER-ELECT Dear Ms. 0auley: We are pleased to confirm our understanding of th6 terms of.our engagement and the nature and Lyle Ez Piermcill,CPA limit6ti , of o n s,,' the services we are"to provide for the City of Palmy springs, OF-COMEL David S.Suss,CPA We will;apply the following,agreed-upon procedures for the period Irqm Jully'l, 2014 through. OF COUNSEL June ld,-201tl,which you have,spe6ified: Howard Gordon,CPA a Verify all Measure J sales tax receipts from the State- of California' by reviewing: remittance documentation,bank records,,andjaccounting records ll�M.20071 Lloyd Maryonov,CPA (1933,2007) * Verify a selection.of individual disbursements of funds'totaling,approximately 5006 of the A Etta E.Coare6ell.CPA total gross disbursements to ensure a that the:funds rp being.spent,6n-,Opprd'Ved,M66sure J projects, The fbIlowing-proc.edures Will be pkrf9mfed: c, Review selected disbursements • Agree the amount of each disbursernent.with approvedvendoir documentation • Review the.approval of each,expenditure • Review the timing of each expenditure. ,0 Review and report on project budget-variances • Provide an annual rep ort to the Mayor, City; Council, mid: the Measure J qversight Committee. Such,riaport will conslst:of the following: o A written descrIption.of the procedures that we performed. o Awriften description,of the revenues and ex end turesCov�p erqa by-ou(OPM o A written description of any errors..or irregularities no te di reg#r4l6ss.oi`nature'or �, 801 E.Ted quh Cqnyob Way amount Our. engagement to apply agrebd-upon procedures,wriill be. conducted in accordance with CA 9226Za7a3 attestation standards estd1bllShe,d0,y the Americ*Institute of Certified-ed Public Accountants, The, A0.86%1826 sufficiency of:the procedures performed or tobep6rf6rmed1s solely the responsibility of those, Pohrn SpilnOs parties, specified in "the report. Consequently,'we make! no jjprjs6fitdtid6 regarding',*the; CA9226,30826 sufficiency of the, procedures described above either for the purpose for-whichAthis (�qpqq has beearequ6ste&or for any other purpose. (760).320!6642 (760)327-6854,FAX City of Palm Springs December 10,2019 Page 2 Because the agreed-upon procedures listed above do not constitute an examination, we will not express an opinion or conclusion on the selection of criteria appropriate for your purposes. In addition,we have no obligation to perform any procedures beyond those listed above. We will issue a written report upon completion of our engagement that lists the procedures performed and our findings. Our report will be addressed to the City of Palm Springs,the Mayor, City Council, and the Measure J Oversight Committee. If, for any reason, we are unable to complete any of the procedures, we will describe in our report any restrictions on the performance of the procedures, or not issue a report and withdraw from this engagement. You understand that the report is intended solely for the information and use of the City of Palm Springs, the Mayor, City Council, and the Measure J Oversight Committee, and should not be used by anyone other than these specified parties. Our report will contain a paragraph indicating that had we performed additional procedures,other matters might have come to our attention that would have been reported to you. An agreed-upon procedures engagement is not designed to detect instances of fraud or noncompliance with laws or regulations; however, we will communicate to you any known and suspected fraud and noncompliance with laws or regulations affecting the selection of criteria that comes to our attention. In addition, if, in connection with this engagement, matters come to our attention that contradicts selecting the criteria, we will disclose those matters in our report. You are responsible for selecting the criteria and determining that such criteria and procedures are appropriate for your purposes.You are also responsible for, and agree to provide us with, a written assertion about selecting the criteria. In addition,you are responsible for providing us with (1) access to all information of which you are aware that is relevant to the performance of the agreed-upon procedures on the subject matter, (2) additional information that we may request for the Purpose of performing the agreed-upon procedures, and (3) unrestricted access to persons within the entity from whom we determine it necessary to obtain evidence relating to performing those procedures. At the conclusion of our engagement,we will require certain written representations in the form of a representation letter from management that, among other things, will confirm management's responsibility for selecting criteria appropriate for your purposes. Steven T. Erickson, CPA, is the engagement partner and is responsible for supervising the engagement and signing the reports or authorizing another individual to sign it Our fees for these services will not exceed $2,500 including any out-of-pocket costs such as report production, word processing, postage, etc. The fee estimate is based on anticipated cooperation from your personnel and the assumption that unexpected circumstances will not be encountered during the engagement. If significant additional time is necessary, we will discuss it with you and arrive at a new fee estimate before we incur the additional costs. Our invoices for these fees will be rendered each month as work progresses and are payable on presentation. In accordance with our firm policies,work may be suspended if your account becomes thirty days or more overdue and will not be resumed until your account is paid in full. If we elect to terminate our services for nonpayment, our engagement will be deemed to have been completed upon written notification of termination even if we have not completed our report. You will be obligated to compensate us for all time expended and to reimburse us for all out-or-pocket expenditures through the date of termination. City"of Palm Springs December`10;2019 Page"3 In theevent of a dispute;over fees for,our engagement, we-mutually agree to try in good.faith to resolve the dispute. If we are,unable to resolve the fee,dispute,:the:City of Palm;Springs,and Maryanov Madsen Gordon&,Campbell, CPAs'agree 1d be,heard. and adjudicated by a retired Federel District Judge, a retired.United States Courtof be, Judge, a retired Justice of the California Supreme Court; or a retired Justice of the California Court of Appeals. Such adjudication shall be binding and final, In agreeing#o this, we both acknowiedge.that in theevent of a dispute over fees, each of us is giving up the right to have the dispufe.tlecidedin a court law before a;iudge or jury and instead are'accephng thisuse of resolution': We appreciate the.opportunity'to assist you and believe this letter accurately summarizes the significant terms of-_our engagement. If you have any questions, please lei us know. If you agree with the terms of our engagement as described in.this letter; please sign the enclosed copy and return into_us If the need-for addiGonal;procedures arises;our agreementwith you.will need to beFrevised., It is:customary for us"to�enumerate these,revisions in an addendum to this letter, If additional specified parties of the report are,,added, we;will require-that they.'acknowledge in wrifing fheirresponsibility forthe sufficiency of procedures: Very truly yours, . Steven T. Erickson,;CPA STE(ml Enclosures RESPONSE: This letter correctly sets forth the,understanding of City of Palm Springs. UU��jj uen., APPROVED BY CRY MANAGER rf Title; Cyl � � J. AWZILk APPROVED AS TO FORM f YK1 ST. By: / Title: yew � Cler MARYMAD-01 GABRIELLEFONTAINE D CERTIFICATE OF LIABILITY INSURANCE 12/19/20 9 ) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements). PRODUCER CONTArIACT Sherry Parlan NFP Prope�y&Casualty Services,Inc. 400 S FarrellDnve lac°.No,E:t:(858)869.8331 juc,Nef(858)869-8301 Suite B-170 nou,E E.Sherry.Parian@nfp.com Palm Springs,CA 92262 INSURERS AFFORDING COVERAGE NAICk INSURER A:Sentinel Insurance Company Ltd 11000 INSURED INSURER B:Hartford Accident and IndemnityCo. 22357 Maryanov Madsen Gordon&Campbell,CPAs,A PC INSURER c:AS en American Insurance Company 43460 PO Box 1826 Suite 200 INSURER D: Palm Springs,CA 92263 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL ABILITY EACH OCCURRENCE 5 2,000,000 CLAIMS-MADE �X OCCUR X 72SBAZX6664 2/612019 216/2020 DAMAGE TO RENTED 5 1,000,000 PREMISES(Fa occumerce)MED EXP(Any oneperson) S 10,000 PERSONAL&AOV INJURY S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 43000,000 X POLICY j LOC PRODUCTS-COMP/OP AGG 5 4,000,000 OTHER S A AUTOMOBILE LIABILITY COeBINEDI SINGLE LIMIT S 2,000,000 (EaANY AUTO 72SBAZX6664 2/612019 2/6/2020 BODI LV INJURY Per persom S OVMED SCHEDULED AUTOS ONLYN AUTOSVWyryryEEpp BODILY INJURY Per accident 5 Ix AUTOS ONLV AUTO�ONLY Pe�eiGtlentDAMAGE S S A X UMBRELLA LIAR X OCCUR EACH OCCURRENCE 5 4,000,000 EXCESS LIAR CLAIMS-MADE 72SBAZX6664 2/612019 21612020 AGGREGATE S 4,000,000 DED I X I RETENTIONS 10,000 S B WORKERS COMPENSATION X PER OTRH- AND EMPLOYERS'LIABILITY ISTATUTE A(N.11 NV PROPREIETOERp/PARTNER/EXECUTNE YIN 72WECGE1073 411/2019 41112020 E.L.EACH ACCIDENT S 13000,000 MenEatoM in NH EXCLUOED4 O NIA 1,000,000 rY I E.L.DISEASE-EA EMPLOYE 5 IT yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5 C E&OlProfessional Lia ACCTI00024-00 111/2019 111/2020 Each Claim 1,000,000 C E&O/Professional Lia ACCTI00024-00 1/112019 111/2020 Aggregate 13000,000 DESCRIPTION OF OPERATIONS I LOCATONS I VEHICLES (ACORD 101,Additional Remarks Schedule,ma,beattached it more space is required) City of Palm Springs is named Additional Insured as respects to General Liability.This insurance is primary and non-contributory with any other insurance of the additional insured,so long as a written contractor agreement to such exists prior to a loss. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CI Of Springs THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City PalmACCORDANCE WITH THE POLICY PROVISIONS. 3200 E.Tahquitz Canyon Way P.0.Box 2743 Palm Springs,CA 92263 AUTHORIZED REPRESENTATIVE -00-_ told ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD BUSINESS LIABILITY COVERAGE FORM (6) When You; Are Added As' An When this insurance is excess over other, Additional' Insured To Other insurance, we will pay only our share of Insurance the amount of the loss, if any, 'that That is other insurance available to exceeds the sum of: you covering liability for damages (1) The total amount that all such other arising out of the premises or' insurance would pay for the loss in the operations, or products and completed absence of this insurance;and operations, for which you have been (2) The total of all deductible and self- added as an additional insured by that insured amounts under all that other insurance;or insurance. (7) When You Add Others As An We will share the remaining loss; if any,,with Additional , Insured To This ' any other insurance that is not described in Insurance this Excess Insurance provision and was not That is other insurance available to an bought specifically to apply in excess of the additional insured. Limits of Insurance shown in the However, ,the following provisions Declarations of this Coverage Part. apply to other insurance available'to c.' Method Of Sharing any person or organization who is an If all the. other insurance permits additional insured under this Coverage contribution by equal shares,we will follow Part: this method also. Under this approach, (a) Primary Insurance When " each insurer contributes equal amounts Requlred,By Contract until it has paid its applicable limit of This insurance is primary if.you" insurance or none of the loss remains, have agreed in a written contract, whichever comes first. written agreement or permit that If any of the other insurance does not permit this insurance be primary. If other contribution by equal shares, we will Insurance is also primary, we will contribute by limits. Under this method;each share with all that other insurance insurers share is based on the ratio of its by the method described !in C. applicable limit of insurance to the total below. applicable limits of insurance of all insurers. (b) Primary And Non-Contributory 8: Transfer Of Rights Of Recovery Against To Other Insurance When Others To Us Required By Contract a. Transfer Of Rights Of Recovery If you have agreed in a written If the insured has rights to recover all or contract, written agreement or part of ,any payment, including permit that this insurance is Supplementary Payments, we have made primary and non-contributory with under this Coverage Part, those rights are the additional insured's own transferred to us. The insured must do insurance, this insurance. is nothing after loss to impair them. At our primary and we will not seek request, the insured will bring "suit" or contribution from that other transfer those rights to us and help us insurance. enforce them. This condition does not. Paragraphs(a)and (b)do not apply to apply to Medical Expenses Coverage. other insurance.to which the additional b. Waiver Of Rights Of Recovery (Waiver insured has been added as an Of Subrogation) additional insured. If the insured has waived any rights of When this insurance 'is excess, we will recovery' against any person or have no duty under this Coverage Part to organization for all or part of any payment, defend the Insured against any"suit'if any including Supplementary Payments, we other insurer has a duty to defend the have made under this Coverage Part, we insured against that "suit". If no other also waive that right, provided the insured insurer defends, we will undertake to do waived their rights of recovery against so, but we will be entitled to the insured's such person or organization in a contract, rights against all those other insurers. agreement or permit that was executed prior to the injury or damage. Form SS 00 08 04 05 Page 17 of 24 THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 December 18, 2019 NFP PROPERTY&CASUALTY SVCS INC/72186686 400 S FARRELL DR SUITE B170 PALM SPRINGS CA 92262 Policy Information: Policy Holder Details: MARYANOV, MADSEN, GORDON & CAMPBEL PO BOX 1826 PALM SPRINGS CA 92263 Policy Number: 72 WEC GE1073 Enclosed please find information pertaining to your policy. Please contact us if you have any questions or concerns. Thank you for selecting The Hartford for your business insurance needs. Sincerely, Your Hartford Service Team WLTRO04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CHANGE IN INFORMATION PAGE INSURER: Hartford Accident and Indemnity Company NCCI Company Number: 10448 Audit Period: ANNUAL Policy Effective Date: 04/01/19 Policy Expiration Date: 04/01/20 Policy Number: 72 WEC GE1073 Endorsement Number: 1 Effective Date: 12/18/19 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: MARYANOV, MADSEN, GORDON & CAMPBELL, CPAS,A PC PO BOX 1826 PALM SPRINGS CA 92263 FEIN Number: 95-3178278 Producer Name: NFP PROPERTY& CASUALTY SVCS INC Producer Code: 72186686 It is agreed that the policy is amended as follows: This is NOT a bill. However, any changes in your premium will be reflected in your next billing statement. You will receive a separate bill from The Hartford. If you are enrolled in repetitive EFT draws from your bank account, changes in premium will change future draw amounts. In consideration of an additional premium of$242, it is agreed that: Policy is amended to add the following condition(s): Waiver of Our Right to Recover from Others Endorsement Policy is amended to add the following Endorsement Forms reflecting the changes made to your policy. WC040306 PN049901 G WC990006A(.2) WC990006A(.1 P) Policy is amended to delete the following Endorsement Forms reflecting the changes made to your policy. PN049901F Countersigned by Authorized Representative Form WC 99 00 06 A (1) Printed in U.S.A. Page 1 Process Date: 12/18/19 Policy Expiration Date: 04/01/20 CHANGE IN INFORMATION PAGE (Continued) Policy Number: 72 WEC GE1073 SCHEDULE IT IS AGREED THAT THE POLICY IS AMENDED AS FOLLOWS: CLASS CODE NUMBER AND DESCRIPTION ESTIMATED RATES PER 100 ESTIMATED TOTALANNUAL OF ANNUAL REMUNERATION REMUNERATION PREMIUMS CA Total State Summary Waiver charge 0.00 250 Small Policy Credit 0.00 6 -15 CA User Fund 0.00 1.447900 3 CA Fraud 0.00 0.287800 1 CA Subsequent Injuries Benefit Trust Fund Assessments 0.00 0.273700 1 CA Occupational Safety& Health Fund 0.00 0.376500 1 CA Labor Enforcement& Compliance Fund 0.00 0.343100 1 California Total Cost 242 Form WC 99 00 06 A (1) Printed in U.S.A. Page 2 Process Date: 12/18/19 Policy Expiration Date: 04/01/20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number: 72 WEC GE1073 Endorsement Number: 1 Effective Date: 12/18/19 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: MARYANOV, MADSEN, GORDON &CAMPBELL, CPAS,A PC PO BOX 1826 PALM SPRINGS CA 92263 We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This'agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration'of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 5% of the California workers'compensation premium otherwise due on such remuneration. SCHEDULE Person or Organization Job Description The City of Palm Springs, Its Officialsm Employees and 01 agents, Department of Finance and Treasury, 3200 E Tahquitz Canyon Way, P.O Box 2743 Palm Springs, CA 922963 Countersigned by Authorized Representative Form WC 04 03 06 (1) Printed in U.S.A. Process Date: 12/18/19 Policy Expiration Date: 04/01/20 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number: 72 WEC GE1073 Endorsement Number: 1 Effective Date: 12/18/19 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: MARYANOV, MADSEN, GORDON & CAMPBELL, CPAS,A PC PO BOX 1826 PALM SPRINGS CA 92263 We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be % of the California workers' compensation premium otherwise due on such remuneration. Countersigned by Authorized Representative Form WC 04 03 06 (1) Printed in U.S.A. Process Date: 12/18/19 Policy Expiration Date: 04/01/20 POLICYHOLDER NOTICE YOUR RIGHT TO RATING AND DIVIDEND INFORMATION I. Information Available to You A. Information Available from Us- Hartford Accident and Indemnity Company (1) General questions regarding your policy should be directed to your Hartford Agent or Hartford Accident and Indemnity Company 3600 WISEMAN BLVD SAN ANTONIO TX 78251 Telephone: (877) 853-2582 www.thehartford.com (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 customerservice(")awcirb.com (email). The regulations contained in the USRP and ERP are available for public viewing through the WCIRB's 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). Form PN 04 99 01 G (03/19) Printed in U.S.A. Page 1 of 3 Process Date: 12/18/19 Policy Expiration Date: 04/01/20 (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. 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: Hartford Accident and Indemnity Company One Hartford Plaza, T.4.175, Hartford, CT 06155; Telephone (800)451-6944; Fax(860)723-4289. After you send your Complaint and Request for Action, we have 30 days to send you a written notice indicating whether or not your written request will be reviewed. If we agree to review your request, we must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If we decline to review your request, if you are dissatisfied with the decision upon review, or if we fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below. B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission to act of the WCIRB, you may request, in writing, that the WCIRB reconsider its decision, action, or omission to act. You may also request, in writing, that the WCIRB review the manner in which its rating system has been applied in connection with the insurance afforded or offered you. For requests related to classification disputes, the reporting of experience, or coverage issues, your initial request for review must be received by the WCIRB within 12 months after the expiration date of the policy to which the request for review pertains, except if the request involves the application of the Revision of Losses rule. For requests related to your experience modification, your initial request for review must be received by the WCIRB within 6 months after the issuance, or 12 months after the expiration date, of the experience modification to which the request for review pertains, whichever is later, except if the request for review involves the application of the Revision of Losses rule. If the request involves the Revision of Losses rule, the time to state your appeal may be longer. (See Section VI, Rule 7 of the ERP). You may commence the review process by sending the WCIRB a written Inquiry. Written Inquiries should be sent to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Customer Service. Customer Service can be reached at 888.229.2472 (phone), 415.778.7272 (fax) and customerservice(a)wcirb.com (email). If you are dissatisfied with the WCIRB's decision upon an Inquiry, or if the WCIRB fails to respond within 90 days after receipt of the Inquiry, you may pursue the subject of the Inquiry by sending the WCIRB a written Complaint and Request for Action.After you send your Complaint and Request for Action, the WCIRB has 30 days to send you written notice indicating whether or not your written request will be reviewed. If the WCIRB agrees to review your request, it must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If the WCIRB declines to review your request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner as described in paragraph II.C., below. Written Complaints and Requests for Action should be forwarded to: WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Complaints and Reconsideration. The WCIRB's contact information is 888.229.2472 (phone), 415.371.5204 (fax)and customerservice(o).wcirb.com (email). Form PN 04 99 01 G (03/19) Printed in U.S.A. Page 2 of 3 C. California Department of Insurance — Appeals to the Insurance Commissioner. After you follow the appropriate dispute resolution process described above, if (1) we or the WCIRB decline to review your request, (2) you are dissatisfied with the decision upon review, or (3) we or the WCIRB fail to grant or reject your request or issue a decision upon review, you may appeal to the Insurance Commissioner pursuant to CIC Sections 11737, 11752.6. 11753.1 and Title 10, California Code of Regulations, Section 2509.40 et seq. You must file your appeal within 30 days after we or the WCIRB send you the notice rejecting review of your Complaint and Request for Action or the decision upon your Complaint and Request for Action. If no written decision regarding your Complaint and Request for Action is sent, your appeal must be filed within 120 days after you sent your Complaint and Request for Action to us or to the WCIRB.The filing address for all appeals to the Insurance Commissioner is: Administrative Hearing Bureau California Department of Insurance 45 Fremont Street, 22nd Floor San Francisco, CA 94105 415.538.4102 You have the right to a hearing before the Insurance Commissioner, and our action, or the action of the WCIRB, may be affirmed, modified or reversed. Ill. Resources Available to You in Obtaining Information and Pursuing Disputes A. Policyholder Ombudsman. Pursuant to California Insurance Code Section 11752.6, a policyholder ombudsman is available at the WCIRB to assist you in obtaining and evaluating the rating, policy, and claims information referenced in I.A. and I.B., above. The ombudsman may advise you on any dispute with us, the WCIRB, or on an appeal to the Insurance Commissioner pursuant to Section 11737 of the Insurance Code. The address of the policyholder ombudsman is WCIRB, 1221 Broadway, Suite 900, Oakland, CA 94612, Attn: Policyholder Ombudsman. The policyholder ombudsman can be reached at 415.778.7159 (phone), 415.371.5288 (fax) and ombudsmanawcirb.com (email). B. California Department of Insurance - Information and Assistance. Information and assistance on policy questions can be obtained from the Department of Insurance Consumer HOTLINE, 800.927.HELP (4357) or insurance.ca.gov. For questions and correspondence regarding appeals to the Administrative Hearing Bureau, see the contact information in paragraph II.C. This notice does not change the policy to which it is attached. Form PN 04 99 01 G (03119) Printed in U.S.A. Page 3 of 3