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Group Self-Insured Workers' Compensation Plan <br /> Administrator <br /> <br /> Berkley Administrators <br /> a mem~r of ~ Berkley Risk Mar{agement Services GrOup .'. !'.i~ .~,.'..: . <br /> <br /> (RENEN~L of ~greemen~ No, 0~-0005[3-[0) <br /> <br />ELK R[VER~ ELK RIVER UT[L[T[ES~ HR~ & ED~ <br /> <br />1010111995 <br /> <br />10/01/1997 <br /> <br /> ESTIMATED DEPOSIT <br />CODE RATE PAYROLL PREMIUM <br /> <br />SEE ATTACHED SCHEDULE FOR DETAILS <br /> <br /> Manual Premium 15)t)~ 109745. <br />Experience Modification 0.81 · ~ <br /> Standard ~_~.emium ~1,99~ 888~3. <br /> Managed C~ ~'~'~ I0.00~ ~ 9~W 888~. <br /> Deductible Credit t~ 0% }~ 4f~ /~0. <br /> <br /> Premium Discount <br />Discounted Standard Premium <br />Insurance Trust Discount O~ <br />Net Deposit Premium <br /> <br />LMC <br /> <br /> 7970. <br />78034. <br /> O. <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 />BA 441CG (12/92) <br /> <br /> <br />