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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 /> Notice of Premium Options for Standard Premiums of $100,000-$150,000 <br /> <br />ELK RIVER, ELK RIVER UTILITIES ,HRA EDA Agreement No.: 0200051318 <br />13065 ORONO PARKWAY Agreement Period: From: 10/01/2003 <br /> <br />ELK RIVER MN 55330 To: 10/01/2004 <br /> <br />Enclosed is a quotation for workers~ compensation deposit premium. <br /> Eq TIK~' ^ TED <br />PAYROLL DESCRIPTION CODE RATE PAYROLL <br /> <br /> SEE ATTACHED SCHEDULE FOR DETAILS <br /> <br />DEPOSIT <br />PREMIUM <br /> <br /> Manual Premium <br />Experience Modification .78 <br />Standard Premium <br /> Deductible Credit 0% <br /> Premium Discount <br /> Net Deposit Premium <br /> <br />181870. <br />141859. <br /> <br />14006. <br />127853. <br /> <br />MANAGED CARE CREDIT <br />Cities that enroll with a state-certified managed care organization(MOO) receive a 3 % premium credit on <br />their work comp coverage. <br /> <br /> Standard Managed Care Net Deposit <br /> Premium Credit Premium <br /> 141859. 3% 123597. <br /> <br />OPTIONS <br />Please indicate below the premium option you wish to select. You may choose only one option and <br />cannot change options during the agreement period. <br /> NET DEPOSIT PREMIUM <br /> 127853. <br />1. <br /> Regular <br /> Premium <br /> Option <br /> ~_ or, with 3% Managed Care Credit: <br /> 123597. <br /> mmm <br /> <br />LM 4514(3/02) <br /> <br /> <br />