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<br />..............::;,.......... ......a .........___. _.____ .___ <br /> <br />I IL-VL..o.I V l..U <br /> <br />Group Self.lnsured Workers' Compensation Plan <br />Administrator <br />Berkley Administrators <br />o mombo' of tho Berkley Risk Management Services Group <br />P.O. Box 59143 Minneapolis.MN 55459-0143 Phone (612) 544-0311 <br /> <br />AUGZ 2 1994' <br />Ans'd <br /> <br />NOTICE OF PREMIUM OPTIONS <br />FOR SfANDARD PREMWMS OF $50.000 $150.000 <br /> <br />. <br /> <br />The 'City. <br /> <br />Agreement No.:. <br />Agreement Period: <br />From: <br />To: <br /> <br />02-000513-9 <br /> <br />ELK RIVER, HOUSING & REDEVELOPMENT, ECONOMIC <br />DEVELOPMENT AUTHORITY & LIBRARY BOARD <br />PO BOX 490, 13065 ORONO PARKWAY <br />ELK RIVER MN 55330-0490 <br />Enclosed is a quotation for workers' compensation deposit premium. Deductible options are now available in rerum for <br />a preIT'jum credit applied to your estimated standard premium of $ 1 282 . The deductible will apply per <br />occurrence 10 paid medical costs only. There is no aggregate limit. 1 1 . <br /> <br />10/01/1994 <br />10/0111995 <br /> <br />OPTIONS <br /> <br />NETDEPOSIT~ <br /> <br />10 <br /> <br />Regular Premium Option <br />Deductible Options: <br /> <br />Deductible <br />oer Occurrence <br />$250 <br />500 <br />1,000 <br />2,500 <br />5,000 <br />10,000 <br /> <br />100914. <br /> <br />2 0 <br />3 0 <br />4 O. <br />5 D <br />6 0 <br />7 0 <br /> <br />Premium <br />Credit <br />2% <br />4% <br />5% <br />9% <br />12% <br />17% <br /> <br />Credit <br />Amount <br />2226. <br />4451. <br />5564. <br />100/5. <br />13354. <br />18918. <br /> <br />98688. <br />96463. <br />95350. <br />90899. <br />87560. <br />81996. <br /> <br />8 0 <br />9 D <br />100 <br /> <br />Retrospectively Rated Premium Options: <br />Retro-Rated Minimum Maximum Maximum <br />Minimum Factor Premium Factor Premium <br />52.9% 130% <br />49.9% 58868. 140%.144667. <br />47.3% 55530. 150% 155795. <br />52636. 166923. <br /> <br />This should be signed by an authorized representative of the city requesting coverage. One of the above options must <br />be selected. Please return a signed copy of this notice to the Administrator with payment and make checks payable to <br />the LMCIT. <br /> <br />(See #1 above <br />for net deposit <br />premium) <br /> <br />Tille <br /> <br />. <br /> <br />Signarure <br /> <br />Date <br /> <br />For more information on the premium options that apply to your city, refcr to the enclosed brochures. <br />BA 4503CG (4/93) <br /> <br /><J. <br />