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League of Minnesota Cities Insurance Trust <br />Group Self- Insured Workers' Compensation Plan <br />145 University Avenue West St. Paul, MN 55103 -2044 Phone (651)215 -4173 <br />Notice of Premium Options for Standard Premiums of $25,000 - $50,000 <br />LITTLE CANADA, CITY OF <br />515 LITTLE CANADA ROAD <br />LITTLE CANADA MN 55117-1633 <br />Enclosed is a quotation for workers' compensation deposit premium. <br />PAYROLL DESCREPTION <br />Agreement No.: 0200006422 <br />Agreement Period: From: 4/01/2012 <br />To: 4/01/2013 <br />ESTIMATED DEPOSIT <br />CODE RATE PAYROLL PREMIUM <br />SEE ATTACHED SCHEDULE FOR DETAILS <br />Manual Premium 28509. <br />Experience Modification 1.06 <br />Standard Premium 30220. <br />Deductible Credit 0% <br />Premium Discount 2396. <br />Net Deposit Premium 27824. <br />OPTIONS <br />Please indicate below the premium option you wish to select. You may choose only one option <br />and you cannot change options during the agreement period. <br />NET DEPOSIT PREMIUM <br />I. Premium Option 27824. <br />LM4514 (3/02)(Rev.01 / 10) <br />3 <br />