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1~ <br />League of Minnesota Cities Insurance Trust <br />Group Self-Insured Workers' Compensation Plan <br />Administrator <br />Berkley Administrators <br />a member of the Berkley Risk Management Services Group <br />P.O. Box 59143 Minneapolis, MN 55459-0143 Phone (612) 544-0311 <br />Self-Insured Workers' Compensation Quotation <br />(REhtEWAL of Agreement No. 02-000513-9) <br />ELK RIVER, ELK RIVER UTILITIES, <br />10/Oi/1995 10/01/1996 <br />ESTIMATED <br />CODE RATE PAYROLL <br />SEE ATTACHED SCHEDULE FOR DETAILS <br />Manual Premium <br />10% Sick, Holiday, & Vacation Allowance <br /> <br />Add. Manual Premium <br />Experience Modification 0.82 <br />Standard Premium <br />Managed Care Credit OY <br />Deductible $2,500. Deductible Credit 9I <br />Premium Discount <br />Discounted Standard Fremium <br />LMC Insurance Trust Discount 0'/, <br />l~let Deposit Fremium <br />DEPOSIT <br />PREMIUM <br />151443. <br />15144. <br />136299. <br />111765. <br />0. <br />0. <br />10425. <br />IOI340. <br />0. <br />10i340. <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 area 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 />• 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 />BA 441CG (12/92) <br />