Laserfiche WebLink
<br />- League of Minnesota Cities Insurance Trust <br />Group Self-Insured Workers' Compensation Plan ~~(;1~1V~~ <br />Administrator <br />. Berkley Administrators s~~p ~ ~ 5~` <br />Member of the W. R. Berkley Group <br />P.O. Box 59143 Minneapolis, MN 55459-0143 Phone (612) 544-0311 ~S'~ __ ----.------- <br />NOTICE OF PREMIUM OPTIONS <br />FOR STANDARD PREMIUMS OF $50,000 - $150,000 <br />The 'City" Agreement No.: <br />Agreement Period: - 02-000513-10 <br />ELK RIVER, ELK RIVER UTILITIES, From: <br />HOUSING & REDEV. AUTH. ECON.AU & SCHOOL BOARD To: 10/01/1995 <br />PO BOX 490, 13065 ORONO PARKWAY 10/01/1996 <br />ELK RIVER hfN 55330-0490 <br />Enclosed is a quotation for workers' compensation deposit premium. Deductible options are now available in return <br />for a premium credit applied to your estimated standard premium of $ .The deductible will apply <br />per occurrence to paid medical costs only. There is no aggregate lirr~i}1765. <br />As an alternative, cities with a standard premium in excess of $25,000 may select from several retro-rated premium <br />options. The final net cost under the retro-rated option equals the audited standard premium times the minimum <br />factor plus losses and all loss-related costs, not to exceed the audited standard premium times the maximum factor. <br />The net cost for each retro option based on your estimated payroll, would be between the minimum and maximum <br />amounts shown below, depending upon your losses. Adjustments will be made approximately six months after the <br />close of your agreement year and annually thereafter until all claims are closed. These adjustments will be based <br />on audited payroll amounts and reserved as well as paid losses. <br />Please indicate below the premium option you wish to select. You may choose only one and you cannot change <br />~tions during the agreement period. <br />OPTIONS <br />NET DEPOSIT PREMIUM <br />1 ^ Regular Premium Option <br />Deductible Options: 101340. <br />Deductible Premium Credit <br />per Occurrence Credit Amount <br />$ 2235. 99105. <br />500 <br />3 ^ 4% <br />44?1. 9b869. <br />4 ^ 1,000 Solo <br />5588. 9J752. <br />5 ^ 2,500 9% <br />10059. 91281. <br />6 ^ 5,000 12% <br />13412. 87928. <br />7 ^ 10,000 17% <br />19000. 82340. <br />Retrospectively Rated Premium Options: <br />Retro-Rated Est. Minimum Maximum Est. Maximum (See #1 above <br />Minimum Factor Premium Factor Premium for net deposit <br />8 ^ 52.9% 59124. 130% 145295. premium) <br />9 ^ 49.9% 55771. 140% 156471. <br />10 ^ 47.3% 52865. 150% 167648. <br />This should be signed by an authorized representative of the city requesting coverage.Oneof the above options must <br />selected. Please return a signed cop y of this notice to the Administrator with payment and make checks payable <br />o the LMCIT. <br />Signature Title Date <br />For more information on the premium options that apply to your city, refer to t he enclosed brochures. <br /> T A ncn~~~ iininn~ <br />