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<br />- <br />League of Minnesota Cities Insurance Trust <br />Group Self-Insured Workers' Compensation Plan <br /> <br />Administrator <br /> <br />Berkley Administrators <br />. member of rho Berkley Risk Management Services Group <br />P.O. Box 59143 Minneapolis. MN 55459-0143 Phone (612) 544-0311 <br /> <br />. <br /> <br />Self-Insured Workers' Comoensation Ouotation <br /> <br />(RENEWAL of Agreement No. 02-000513-8) <br /> <br />ELK RIVER, HOUSING & REDEVELOPMENT, ECONOMIC <br /> <br />10/01/1994 <br /> <br />10/01/1995 <br /> <br />. <br /> <br />STREET CONSTRUCTION & MAINTENANCE <br />WATERWORKS <br />ELECTRIC & STEAM PLANT <br />FIREFIGHTERS (VOLUNTEER) <br />POLl CE <br />OFF SALE LIQUOR STORE <br />CITY SHOP & YARD <br />CLERICAL <br />PARKS <br />MUNICIPAL EMPLOYEES <br />ELECTED OR APPOINTED OFFICIALS <br /> <br />CODE '5-r~""'e RATE <br /> <br />5506 :;;l1.9'1 7.47 <br />7520 ~. 0'1 4.77 <br />7539 10. (..j'1l 5.54 <br />7708 9,.~~ 81.82 <br />7720 '6,05 6.54 <br />8017 ~.'(o 2.81 <br />8227 ) I ' I i.. 5 . 72 <br />8810 .yo 0.54 <br />9102 5.G,'d 4.17 <br />9410 .;:~S 2.31 <br />9411 5.t's 2.31 <br /> <br />EST! MA TED <br />PAYROLL <br /> <br />137500. <br />45510. <br />472874. <br />POP 15718. <br />786517. <br />164800. <br />68750. <br />652263. ' <br />68750. <br />283556. <br />25800. <br /> <br />Manual Premium <br />Experience Modification 0.89 <br />Standard Premium <br />Managed Care Credit 0% <br />Deductible Credit 0% <br />Premium Discount <br />Discounted Standard Premium <br />LMC Insurance Trust Discount 0% <br />Net Deposit Premium <br /> <br />DEPOS IT <br />PREMIUM <br /> <br />10271 .c y ~ <br />2171 ::~/7- <br />26197.!j'lr". <br />12860.11/(..; . <br />51438';;:P1 <br />4631.{jL.~/.t/ <br />3933'?&'/~ <br />3522 . ~ {.. t <br />2867.3, I c:; <br />6550 Ie O~ <br />596<~'5. <br /> <br />125036 .A&~5 <br /> <br />1 i 1282./7<190 <br />o. <br />O. <br />10368.17<1~ <br />100914./5?ql <br />o. <br />100914./5741 <br /> <br />The foregoing quotation is for a deposit premium based on your estimate of'payroll. Your final actual <br />premium will be computed after an audit of payroll subsequent to the close of your agreement year and <br />will be subject to revisions in rates, payrolls and experience modification. While you are a member of <br />the LMCIT Workers' Compensation Plan, you will be eligible to participate in distributions from the <br />Trust based upon claims experience and earnings of the Trust. <br /> <br />If you desire the coverage offered above, please complete the enclosed" Application for Coverage" and <br />return it and your check for the deposit premium (made payable to the LMC Insurance Trust) to the Plan <br />Administrator, Berkley Administrators. <br /> <br />. <br /> <br />BA 441eG (12/92) <br /> <br />3 <br />