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League of Minnesota Cities Insurance 'Trust <br /> Group Self-Insured Workers' Compensation Plan <br /> Administrator <br /> <br /> Berkley Administrators <br /> a member of the Berkley Risk Management Services Group <br />P.O. Box 59143 Minneapolis, MN 55459-0143 Phone (612) 544-0311 <br /> <br /> Self-Insured Workers' Compensation Ouotation <br /> <br /> (RENEWAL of Agreement No. 02-000513-11) <br /> <br />ELK RIVER, ELK RIVER UTILITIES, HRA & EDA <br /> <br /> 10/01/1997 10/01/1998 <br /> <br /> ESTIMATED DEPOSIT <br />CODE RATE PAYROLL PREMIUM <br /> <br />SEE ATTACHED SCHEDULE FOR DETAILS <br /> <br />LMC <br /> <br /> Manual Premium <br />Experience Modification 0.78 .~ <br /> Standard Premium 87104. <br /> Managed Care Credit IO.OOX ~c 8710. <br /> Deductible Credit OX O. <br /> Premium Discount 7800. <br /> Discounted Standard Premium 7059~. <br /> Insurance Trust Discount OX O. <br /> Net Deposit Premidm <br /> <br />lll&7~. <br /> <br />The foregoing quotation is for a deposit premium based on your estimate of payroll. Your f'mal actual <br />premium will be computed after an audit of payroll subsequent to the close of your agreement year and <br />will be subject to revisions in rates, payrolls and experience modification. While you are a member of <br />the LMCIT Workers' Compensation Plan, ),ou will be eligible to participate in distributions from the <br />Trust based upon claims experience and earmngs of the Trust. <br /> <br />If you desire the coverage offered above, please complete the enclosed "Application for Coverage" and <br />return it and your check for the deposit premium (made payable to the LMC Insurance TrusO to the Plan <br />Administrator, Berkley Administrators. <br /> <br /> <br />