Laserfiche WebLink
Deductible Premium Option <br />Deductible options are available in return for a premium credit applied to your estimated standard <br />premium of $ 141859. The deductible will apply per occurrence to paid medical costs only. <br />There is no aggregate limit. <br /> <br /> Deductible Premium Credit NET DEPOSIT PREMIUM <br />per Occurrence Credit Amount wi~MCO Cre~t wi~out <br />$250 2.50% 3546. 120051. 124307 <br />$500 4.00% 5674. 117923. 122179 <br />$1,000 6.00% 8512. 115085. 119341 <br />$2,500 9.50% 13477. 110120. 114376 <br />$5,000 13.50% 19151. 104446. 108702 <br />$10,000 18.50% 26244. 97353. 101609 <br /> <br />Retrospective Rates Premium Option <br /> <br />Re~o-Ra~d Est. Minimum Re~o-Rated Est. Maximum <br />Mi~mumFac~r P~mium Maximum Factor Premium <br />.595% 81874. 1.300% 178884. <br />.482% 66325. 1.500% 206405. <br />.338% 46510. 2.000% 275206. <br /> <br />This quotation is for a deposit premium based on your estimate of payroll and selected options. Your final <br />actual premium will be computed after an audit of payroll subsequent to the close of your agreement year <br />and will be subject to revisions in rates, payrolls and experience modification. While you are a member of <br />the LMCIT workers' Compensation Plan, you will be eligible to participate in divident distributions from <br />the Trust based upon claims experience and earnings of the Trust. <br /> <br />If you desire the coverage offered above, please return this signed document and your check for the net <br />deposit premium option you have selected (made payable to the LMCIT) to: <br /> <br />League of Minnesota Cities Insurance Trust <br /> Workers' Compensation Department <br /> P.O. Box 581517 <br /> Minneapolis, MN 55458-1517 <br /> <br />this quotation should be signed by an authorized representative of the city requesting coverage. <br /> <br />Signature Title <br /> <br />Date <br /> <br />LM 4513(3/02) <br /> <br /> <br />