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<br />League of Minnesota Cities Insurance Trust <br />Group Self-Insured Workers' Compensation Plan <br />Administrator <br />Berkley Administrators <br />145 University Avenue West 81. Paul, MN 55103-2044 Phone (651) 215-4169 <br /> <br />. <br /> <br />~~~ <br />~~ <br />.. <br /> <br />Notice of Premium Options for Standard Premiums of $50,000 - $100,000 <br /> <br />The .City" <br />ELK RIVER~ ELK RIVER UTILITIES~ HRA & EDA <br /> <br />Agreement No.: <br />Agreement Period: <br />From: <br />To: <br /> <br />02-000513-14 <br /> <br />10/01/1999 <br />10/01/2000 <br /> <br />PO BOX 490~ 13065 ORONO PARKWAY <br />ELK RIVER MN 55330-0490 <br /> <br />Enclosed is a quotation for workers' compensation deposit premium. Deductible options are now available in return <br />for a premium credit applied to your estimated standard premium of$ 70407.. . The deductible will apply <br />,per occurrence to paid medical costs only. There is no aggregate limit. ; <br /> <br />As an alternative, 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 />. <br /> <br />OPTIONS <br /> <br />1 0 Regular Premium Option <br /> <br />Deductible Options: <br /> <br />Deductible <br />per Occurrence <br />$250 <br />500 <br />1,000 <br />2,500 <br />5,000 <br />10,000 <br /> <br />Premium <br />Credit <br />3% <br />4.5% <br />6% <br />10% <br />13.5% <br />18% <br /> <br />2 0 <br />3 0 <br />4 0 <br />5 0 <br />6 0 <br />7 0 <br /> <br />8 0 <br />9' 0 <br />100 <br /> <br />Retrospectively Rated Premium Options: <br /> <br />Retro-Rated Est. Minimum <br />Minimum Factor Premium <br />67.0% 47173. <br />57.3% 40343. <br />43.2% 30416. <br /> <br />NET DEPOSIT PREMIUM <br /> <br />64193. <br /> <br />Credit <br />Amount <br />2112. <br />3168. <br />4224. <br />7041. <br />9505. <br />12673. <br /> <br />62081 . <br />61025. <br />59969. <br />57152. <br />5l~688 . <br />51520. <br /> <br />Maximum <br />Factor <br />130% <br />150% <br />200% <br /> <br />Est. Maximum (See # 1 above <br />Premium for net deposit <br />91529. premium) <br />105611. <br />140814. <br /> <br />This should be signed by an authorized representative ofthe city requesting coverage. One ofthe above options must <br />_elected. Please return a signed copy oftms notice to us with payment and make checks payable to the LMCIT. <br /> <br /> <br />Signature Title Date <br /> <br />For more information on the premium options that apply to your city, refer to the enclosed brochures. <br /> <br />LM4503(1l/98) <br />