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Deductible Premium Option <br />Deductible options are available in return for a premium credit applied to your estimated standard <br />premium of $ 128438. The deductible will apply per occurrence to paid medical costs only. <br />There is no aggregate limit. <br /> <br /> Deduct~le Premium Credit NET DEPOSIT PREMIUM <br />per Occurrence Credit Amount with MCO Cre~t without <br />$250 3.00% 3853. 108323. 112176. <br />$500 4.50~ 5780, 100390, 11024~, <br />$1,000 6.502 8348. 103828. 107681. <br />$2,500 10.50% 13486. 98690. 102543. <br />$5,000 14.00% 17981. 94195. 98048. <br />$10,000 19.00% 24403. 87773. 91626. <br /> <br />Retrospective Rates Premium Option <br /> <br />Re~o-Ra~d Est.Minimum Retro-Ra~d Est.Maximum <br />MiffimumFactor Premium Maximum Fac~r Premium <br />· 579% 72135. 1.300% 161961. <br />· 474% 59053. 1.500% 186878. <br />· 335% 41736. 2.000% 249170. <br /> <br />This quotation is for a deposit premium based on your estimate of payroll and selected options. Your final <br />actual premium will be computed after an audit of payroll subsequent to the close of your agreement year <br />and 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 divident distributions from <br />the Trust based upon claims experience and earnings of the Trust. <br /> <br />If you desire the coverage offered above, please return this signed document and your check for the net <br />deposit premium option you have selected (made payable to the LMCIT) to: <br /> <br />League of Minnesota Cities Insurance Trust <br /> Workers' Compensation Department <br /> P.O. Box 581517 <br /> Minneapolis, MN 55458-1517 <br /> <br />This quotation should be signed by an authorized representative of the city requesting coverage. <br /> <br />Signature Title Date <br /> <br />LM 4513(3/02) <br /> <br /> <br />