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<br />League of Minnesota Cities Insurance Trust <br />Group Self-Insured Workers' Compensation Plan <br />145 University Avenue vVest St. Paul, IVIN 55103-2044 Phone (651)215-4173 <br /> <br />AUG :2 4 2005 <br /> <br />Notice of Premium Options for Standard Premiums of $150,000-$300,000 <br /> <br />ELK RIVER, CITY OF <br />ELK RIVER UTILITIES, HRA & EDA <br />13065 ORONO PARKWAY <br />ELK RIVER MN 55330 <br /> <br />Agreement No.: 0200051320 <br />Agreement Period: From: 10/01/2005 <br />To: 10/01/2006 <br /> <br />Enclosed is a quotation for workers! compensation deposit premium. <br /> <br />PAYROLL DESCRIPTION <br /> <br />CODE <br /> <br />RATE <br /> <br />ESTIM.A. TED <br />PAYROLL <br /> <br />DEPOSIT <br />PREMIUM <br /> <br />SEE ~A,. TT ACHED SCHEDULE FOR DETAILS <br /> <br />Manual Premium <br />Experience Modification .80 <br />Standard Premium <br />Deductible Credit 0% <br />Premium Discount <br />Net Deposit Premium <br /> <br />260494. <br />208395. <br />21924. <br />186471. <br /> <br />MANAGED CARE CREDIT <br /> <br />Cities that enroll with a state-certified managed care organization(MCO) recei\Te a 3 % premium credit on <br />their work camp coverage. <br /> <br />Standard <br />Premimn <br />208395. <br /> <br />l\1anaged Care <br />Credit <br />3% <br /> <br />Net Deposit <br />Premimn <br />180219. <br /> <br />OPTIONS <br /> <br />Please indicate below the premium option you wish to select. You may choose only one option and <br />cannot change options during the agreement period. <br /> <br />1. ___ Regular Premium Option <br /> <br />NET DEPOSIT PREMIUM <br />186471. <br />___ or) with 3% Managed Care Credit: 180219. <br /> <br />Ll\1 4514(3/02) <br />