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<br />. <br /> <br />. <br /> <br />. <br /> <br />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 (651) 215-4169 <br /> <br />Self-Insured Workers' Compens~tion Quotation <br /> <br />(RENEWAL of Agreement No. 02-000513-13) <br /> <br />ELK RIVER, ELK RIVER UTILITIES, HRA & EDA <br /> <br />10/01/! 999 <br /> <br />10/01/2000 <br /> <br />DEPOSIT <br />PREMIUM <br /> <br />108318. <br /> <br />70407. <br />O. <br />O. <br />6214. <br />64193. <br />O. <br />64193. <br /> <br />"3 ~ ~o <br />. <br /> <br />q $' C> '5' <br />. <br /> <br />, SI. lV' <br /> <br />\ 0/ \ I '\ ~ t.~ ~u lV\o.l. ,1 ~ <br /> <br />\o/l/C\t- \C/l~q 'l,....W\:WW\ *, S~\ ~~ <br />~.~~ ~'il ~ ~CL ~OQ't) dslJu.d\Iola... <br />~~~'TS. . <br />The foregoing quotation is for a deposit premimn 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 from 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 "Notice ofPremimn Options" and return it <br />and your check for the deposit premium (made payable to the LMCIT) to us at the above address. <br /> <br />CODE <br /> <br />RATE <br /> <br />EST! MATED <br />PAYROLL <br /> <br />SEE ATTACHED SCHEDULE FOR DETAILS <br /> <br />Manual Premium <br />Experience Modification 0.65 <br />Standard Premium <br />Managed Care Credit OX <br />Deductible Credit Or. <br />Premium Discount <br />Discounted Standard Premium <br />LMC Insurance Trust Discount OX <br />Net Deposit Premium <br /> <br />f"'\A W'\ ~ 'tr c\. c........ '- ~4! cL ~ \- <br />~ed.v..~I'A\c.. ("fLit- <br />~\ 1)00) <br /> <br />LM4410 (11/98) <br />