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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) 215-4~73 <br /> <br />Self-Insured Workers' Compensation Quotation <br /> <br />(R£NEWAL ~f Am-eement No. 02-005;5!3-!4) <br />RIVER, ELK RIVER UTiLITiES. <br /> <br /> ! 0/01/'2,}00 .t 0/01/~001 <br /> <br /> EST ! MATED DEF'OS i T <br />CODE RATE PA'f ROLL F'F:E?! I UH <br /> <br />SEE ATTACHED SCHEDULE FOR DETAILS <br /> <br /> Manual Premium 124356. <br />Exoerience !dodification <br /> Standard F?smium 96998. <br /> Manacled Care Credit S.00~ 4850. <br /> O~ductibie Credit O~ O. <br /> Premium Discount <br /> Discounted Standarm Premium 8340S. <br /> <br /> Net Deposit Premium ~340~. <br /> <br />The foregoing quotation is for a deposit premium based on your estimate of payroll. Your final actual <br />premium will be computed a~er an audit of payroll subsequent to the close of your agreement year and will <br />be subject to revisions in rates, payrolls and experience modification. While you are a member of the <br />LMCIT Workers' Compensation Plan, you will be eligible to participate in distributions from the Trust <br />based upon claims experience and earnings of the Trust. <br /> <br />If you desire the coverage offered above, please complete the enclosed "Notice of Premium Options" and <br />return it and your check for the deposit premium (made payable to the LMCIT) to: <br /> <br />BerkleyRiskAdministrators Company, LLC <br />PO Box 581517 <br /> Minneapolis, MN55458-1517 <br /> <br />LM 4410 (8/99) <br /> <br /> <br />