Compilation of Rules and Regulations of the State of Georgia
Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER
Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE
Subject 120-2-36 - WORKERS' COMPENSATION INSURANCE STATISTICAL AGENT - FORMS AND RATING PLANS
Rule 120-2-36-.12 - Severability

If any provision of this Regulation, or the application thereof, to any person or circumstance is held invalid by a court of competent jurisdiction, the remainder of the Regulation or the applicability of such provisions to other persons or circumstances shall not be affected.

IMPORTANT

DISCLOSURE STATEMENT

_________________________

Date of Mailing

TO: Policy Holder Carrier's Return Address

Attached, as required by Georgia Law, is a copy of the loss experience to be used in experience rating your workers compensation policy. The experience rating can cause your premiums to increase or decrease depending on the frequency end severity of losses.

In accordance with the O.C.G.A. Section 34-9-136, please review the attached statement, sign below and return this form to our office. If you do not sign and return this form within 30 days from the mailing date, the date will be deemed correct for the purpose of calculating your experience rating modification factor end final premium. Your failure to respond shall not affect nor waive any of your rights to a future appeal.

If you find an error in the attached material, please contact our office immediately at the indicated address:

SIGN THE APPLICABLE STATEMENT BELOW

AND RETURN REQUIRED STATEMENT

I have reviewed the attached payroll and claims information and find it to be accurate. An insurance company representative has explained that this information may affect the premium charged for Workers' Compensation Insurance Coverage for my business.

___________________________________________

SIGNATURE & TITLE

(Authorized Representative of the Employer)

I have reviewed the attached payroll and claims information. According to my records, the information is inaccurate. I have attached a copy of my records which I believe to be correct and a statement explaining the differences. I understand that if you, the insurance company, do not respond to me within 60 days of the date on your statement, you are agreeing with me that my records are correct and you will change your records accordingly.

___________________________________________

SIGNATURE & TITLE

(Authorized Representative of the Employer)

(NOTE: Return by _______________)

Date

IF YOU ARE AN INDIVIDUAL WITH A DISABILITY AND WISH TO ACQUIRE THIS PUBLICATION IN AN ALTERNATIVE FORMAT, PLEASE CONTACT THE ADA COORDINATOR, PROPERTY & CASUALTY DIVISION, OFFICE OF COMMISSIONER OF INSURANCE, NO 2 MARTIN LUTHER KING, JR. DRIVE, ATLANTA, GEORGIA 30334 (404) 656-2056, TDD # (404) 656-4031

O.C.G.A. Secs. 33-2-9, 33-9-20, 33-9-21, 34-9-133, 34-9-135.