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2. — Deductible Premium Option <br />Deductible options are available in return for a premium credit applied to your estimated standard <br />premium of $ 30220. The deductible will apply per occurrence to paid medical costs only, <br />There is no aggregate limit. <br />Deductible Premium Credit Net Deposit <br />per Occurrence Credit Amount Premium <br />*250 1.50% 453. 27371. <br />$500 2.50% 756. 2.7068. <br />$1,000 4.00% 1209. 26615. <br />$2,500 7,00% 2115. 25709. <br />$5,000 10.50% 3173. 24651. <br />$10,000 14.50% 4382. 23442. <br />*25,000 22.00% 6648. 21176, <br />450,000 28.00% 8462. 19362. <br />3 Retrospective Rates Premium Option <br />Retro -Rated Est.Minimum Rciro -Rated Est.Maximum <br />Minimum Factor Premium Maximun Factor Premium <br />.715% 21607. 1.150% 34753. <br />.693% 20942. 1.250% 37775. <br />.648% 19583. 1.500% 45330. <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 dividend distributions from <br />the Trust based upon claims experience and earnings of the Trust. <br />If you desire the coverage offered above, please return this signed document for the option you have <br />selected. <br />This quotation should be signed by an authorized representative of the city requesting coverage. <br />Signature <br />5 <br />Title Date <br />LM4513 (3 /02)(Rev.01/12) <br />