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League of Minnesota Cities Insurance Trust <br /> Group Self-Insured Workers' Compensation Plan <br />145 University Avenue West St. Paul, MN 55103-2044 Phone (651) 215-4173 <br /> <br />Self-Insured Workers' Compensation Quotation <br /> <br />ELK <br /> <br />,:RENEWAL of Agreement No. 0E-000513-1~) <br />RIVER~, ELI--':: RIVER UTILITIES, <br /> <br /> 10101 iF]00 i ! 0101 <br /> <br /> F'oTIMATED DEPOSIT <br />CODE RATE PAYROLL F'R E?'I I UM <br /> <br />SEE ATTACHED SCHEDULE FOR DETAILS <br /> <br /> Manual Premium 141816. <br /> Experience Modification 0.8! <br /> Standard Premium <br /> Managed Care Cred~.t 5.00'~I 5744. <br /> Deductible Credit 0t4 0. <br />Premium Discount t0795. <br />Discounted Standard F'remium <br />Uric Insuranc~ Trust Discount Og 0. <br />N~t Deposit Premium 9833~ <br /> <br />The foregoing quotation is for a deposit premium based on your estimate of payroll. Your final actual <br />premium will be computed after an audit of payroll subsequent to the close of your agreement year and will <br />be subject to revisions in rates, payrolls and experience modification. While you are a member of the <br />LMCIT Workers' Compensation Plan, you will be eligible to participate in distributions from the Trust <br />based upon claims experience and earnings of the Trust. <br /> <br />If you desire the coverage offered above, please complete the enclosed "Notice of Premium Options" and <br />return it and your check for the deposit premium (made payable to the LMCIT) to: <br /> <br />Berkley Risk Administrators Company, LLC <br />PO Box 581517 <br /> Minneapolis, MN 55458-1517 <br /> <br />LM 4410 (8/99) <br /> <br /> <br />