Laserfiche WebLink
Notice <br /> <br /> 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 />of Premium Options for Standard Premiums of $100,000 - <br /> <br />$150,000 <br /> <br /> SEP 2 ZOOt <br />The "City" Agreement No.: 0[~--00051 [~"- _! 6 <br /> ELK RIVER: ELK RIVER UTILITIES, Agreement Period: <br /> HRA &. EDA From: !0/0!/800t <br /> PO BOX 490. 13065 ORONO PARKWAY To: 10/01/800~2 <br /> ELI.':.' RIVER MN 55330-0490 <br /> <br />Enclosed is a quotation for workers' compensation deposit premium. Deductible options are now available in return <br />for a premium credit applied to your estimated standard premium of $ ! ! 4871, The deductible will apply <br />per occurrence to paid medical costs only. There is no aggregate limit. <br /> <br />As an alternative, cities with a standard premium in excess of $25,000 may select from several retro-rated premium <br />options. The fmal net cost under the retro-rated option equals the audited standard premium times the minimum <br />factor plus losses and all loss-related costs, not to exceed the audited standard premium times the maximum factor. <br />The net cost for each retro option based on your estimated payroll, would be between the minimum and maximum <br />amounts shown below, depending upon your losses. Adjustments will be made approximately six months after the <br />close of your agreement year and annually thereafter until all claims are closed. These adjustments will be based <br />on audited payroll amounts and reserved as well as paid losses. <br /> <br />Please indicate below the premium option you wish to select. You may choose only one and you cannot change <br />options during the agreement period. <br /> <br />OPTIONS <br /> <br />1 [] Regular Premium Option <br /> Deductible Options: <br /> <br /> Deductible Premium Credit <br /> per Occurrence Credit Amount <br />2 [] $250 3% <br />3 [] 500 4.5% <br />4 [] 1,000 6% <br />5 [] 2,500 10% <br />6 [] 5,000 13.5% 1550~,, <br />7 [] 10,000 18% a0677. <br /> <br /> Retrospectively Rated Premium Options: <br /> Retro-Rated Est. Minimum Maximum <br /> Minimum Factor Premium Factor <br />8 [] 57.9% 63185. 130% <br />9 [] 47.4% 517-2.5. 150% <br />10 [] 33.5% 3655~;'., 200% <br /> <br />NET DEPOSIT PRE1VIIUM <br /> <br />73163. <br />91440. <br />_R6845. <br /> <br />Est. Maximum (See#1 above <br /> Premium for net deposit <br /> 14 !. ~6S~ premium) <br /> 1636:7'1. <br /> <br />This should be signed by an authorized representative of the city requesting coverage. One of the above options must <br />be selected. Please return a signed copy of this notice to us with payment and make checks payable to the LMCIT. <br /> <br />b]gnature Title Date <br />For more information on the premium options that apply to your city, refer to the enclosed brochures. <br /> <br />LM4507 (8/99) <br /> <br /> <br />