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League of Minnesota Cities Insurance Trust <br /> Group Self-Insured Workers' Compensation Plan <br />145 University Avenue West St. Paul, MN 55103-2044 Phone (651)215-4173 <br /> <br />Notice of Premium Options for Standard Premiums of $100,000-$150,000 <br /> <br />ELK RIVER, ELK RIVER UTILITIES ,HRA <br />PO BOX 490,13065 ORONO PARKWAY <br />ELK RIVER MN 55330 <br /> <br />EDA <br /> <br /> Agreement No.: 0200051317 <br />Agreement Period: From: 10/01/2002 <br /> To: 10/01/2003 <br /> <br />Enclosed is a quotation for workers' compensation deposit premium. <br /> <br /> ESTIMATED <br />PAYROLL DESCRIPTION CODE RATE PAYROLL <br /> <br /> SEE ATTACHED SCHEDULE FOR DETAILS <br /> <br />DEPOSIT <br />PREMIUM <br /> <br /> Manual Premium <br />Experience Modification .79 <br />Standard Premium <br /> Deductible Credit 0% <br /> Premium Discount <br /> Net Deposit Premium <br /> <br />162580. <br />128438. <br /> <br />12409. <br />116029. <br /> <br />MANAGED CARE CREDIT <br /> <br />Cities that enroll with a state-certified managed care organization(MCO) receive a 3 % premium credit on <br />their work comp coverage. <br /> <br /> Standard Managed Care Net Deposit <br /> P~mium Credit P~mium <br /> 128438. 3% 112176. <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 /> NET DEPOSIT PREMIUM <br />1. Regular Premium Option 116029. <br /> or, with 3% Managed Care Credit: 112176. <br /> <br />LM 4514(3/02) <br /> <br /> <br />