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Deductible Premium Option <br />Deductible options am available in return for a premium credit applied to your estimated standard <br />premium of $ 30857. 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% 463. 27938. <br />$500 2.50% 771. 27630. <br />$1,000 3.50% 1080. 27321. <br />$2,500 6.50% 2006. 26395. <br />$5,000 9.50% 2931. 25470. <br />$10.000 14.00% 4320. 24081. <br />$25,000 21.50% 6634. 21767. <br />$50,000 27.50% 8486. 19915. <br />3 Z Retrospective Rates Premium Option <br />Retro-Rated Esl.Minimum Retro•Rated Est.Maximum <br />Minimum Factor Premium Maximum Factor Premium <br />.737% 22742. 1.150% 35486. <br />.715% 22063. 1.250% 38571, <br />.672% 20736. 1.500% 46286. <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 />r 'e LMCIT workers' Compensation Plan, you will be eligible to participate in dividend distributions from <br />ine 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 />6 <br />