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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 (6Sl) 215-4173 <br /> <br />Notice of Premium Options for Standard Premiums of $50,000 - $100,000 <br /> <br />The "C~" Aoreement No.: <br />ELK R ! VE-R. EL,k] R ! VER UT [ L [ T TEE. Agreement Period: <br />HF:~ & ED,A From: <br />PO BOX 4.90. 13065 ORONO PAFd-':.'WA'f To: <br /> ELK RIVER MI'~ 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 $ 76,7<..~. . The deductible will apply <br />per occurrence to paid medical costs only. There is no aggregate limit. <br /> <br />As an altemative, cities with a standard premium in excess of $25,000 may select from several retro-rated premium <br />options. The final 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 />~PTIONS <br /> <br />NET DEPOSIT PREMIUM <br /> <br />1 [] Regular Premium Option <br /> Deductible Options: <br /> <br /> Deductible Premium Credit <br /> per Occurrence Credit Amount <br />2 [] $250 3% :='--7..'t ~_',~ ,'30,;.,-'?...'E~ <br />3 [] 500 4.5% <br />4 [] 1,000 6% <br />5 [] 2,500 10% <br />6 [] 5,000 13.5% <br />7 [] 10,000 18% <br /> <br /> Retrospectively Rated Premium Options: <br /> Retro-Rated Est. Minimum Maximum <br /> Minimum Factor Premium Factor <br />8 [] 67.0% ~ !'..,::~.,. 130% <br />9 [] 57.3% ~EC-..Ot. 150% <br />10 [] 43.2% ~0,'-2. 200% <br /> <br />Est. Maximum (See#1 above <br /> Premium for net deposit <br /> ~_ t .~7~-.~. premium) <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 /> gnature Title Date <br /> <br />For more information on the premium options that apply to Your city, refer to the enclosed brochures. <br /> <br />LM4503 (8/99) <br /> <br /> <br />