Laserfiche WebLink
League of Minnesota Cities Insurance Trust <br /> Group Self-Insured Workers' Compensation Plan <br /> Administrator <br />Berkley Administrators <br />145 University Avenue West St_ Paul, MN 55103-2044 Phone (612) 215-4173 <br /> <br />Self-insured Workers' Compensation Quotation <br /> (RENEWAL of Agreement No. 02-000513-18) <br /> <br />ELK RIVER, ELK RIVER kJTILITES, HRA & EDA ~sED <br /> 10/01/1998 [0/01/1999 REV <br /> <br /> ESTIMATED DEPOSIT <br />CODE RATE PAYROLL PREM I UPI <br /> <br />SEE ATTACHED SCHEDULE FOR DETAILS <br /> <br /> Manual Premium <br /> Experience Modification 0.?4 <br /> Standard Premium <br /> Managed Care Credit 10.00~ <br /> Deductible Credit O~ <br /> Premium Discount <br />Discounted Standard Premium <br />LMC Insurance Trust Discount 0~ <br />Net Deposit Premium <br /> <br />104404. <br /> <br />77859. <br />7786. <br /> <br /> . <br /> 6865. <br />68668. <br /> 0. <br />68668. <br /> <br />The foregoing quotation is for a deposit premium based on your estimate of payroll. Your final actual premium will <br />be computed after an audit of payroll subsequent to the close of your agreement year and will be subject to <br />revisions in rates, payrolls and experience modification. While you are a member of the LMCIT Workers' <br />Compensation Plan, you will be eligible to participate in distributions ~om the Trust based upon Claims experience <br />and earnings of the Trust. <br /> <br />If you desire the coverage offered above, please complete the enclosed '2qotice of Premium Options" and remm it <br />and your check for the deposit premium (made payable to the LMCIT) to us at the above address. <br /> <br />LM 4410 (12/97) <br /> <br /> <br />