Laserfiche WebLink
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY <br />INFORMATION PAGE <br />STATE FUND MUTUAL INSURANCE COMPANY <br />Renewal of No. 002647.204 <br />.rem 1. INSURED. The Insured Mailing Address: <br />CITY OF LITTLE CANADA <br />515 LITTLE CANADA RD <br />LITTLE CANADA RAMSEY MN 55117 <br />INDIVIDUAL <br />PARTNERSHIP <br />Other workplaces not shown above: <br />CORPORATION C OTHER <br />Policy Number0 0 2 6 4 7 . 1 0 5 <br />Agent <br />AGENTS ASSISTANCE CORP <br />4901 W 77TH ST <br />SUITE 148 <br />EDINA MN 55435 <br />MC NAMARA COMPANY <br />Item 2. POLICY PERIOD. From: 0 1 / 0 1 / 9 0 To: 01 / 01 / 9 1 ius neosuuuec°oonESx ME <br />Item 1 COVERAGE. <br />applies to the Workers Compensation Law of Minnesota. <br />to work in Minnesota as listed in item 3A. The Limits of our <br />Bodily Injury by Disease /Accident Bodily Injury by Disease <br />$ 5 0 0 , 0 0 0 policy limit $1 0 0, 0 0 0 each employee <br />to the states, if any, listed here: See Endo'. s e rue tt t WC 2 <br />WC 1 3 1 <br />WC220601 WC19 WC 13 <br />• <br />A. Workers Compensation Insurance: Part One of the policy <br />B. Employers Liability Insurance: Part Two of the policy applies <br />liability under Part Two are: Bodily Injury by Accident <br />$ 1 0 0 , 0 0 0 each accident <br />C. Other States Insurance: Part Three of the policy applies <br />D. This policy includes these endorsements and schedules: <br />WC2 WC1 -1 WC4 WC14 <br />Item 4. PREMIUM. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates <br />and Rating Plans. All information required below is subject to verification and change by audit. <br />Classifications <br />Code <br />No <br />Premium Basis <br />Total Estimated <br />Annual Remuneration <br />Rate Per <br />$100 of <br />Remuneration <br />Estimated Annual <br />premium <br />Clerical Office Employees NOC <br />Water Works Operation <br />Street or Road Construction Pa <br />Parks tIOC All Employees <br />Municipal Township County or 5 <br />Garbage Ashes Refuse Collectin <br />Salesman Collectors or Messeng <br />Street Cleaning <br />Experience Modification 0.88 <br />Premium Discount <br />Expense Constant <br />Minnesota ID %: 1114530 <br />8810 <br />7520 <br />5506 <br />9102 <br />9410 <br />9403 <br />8742 <br />9402 <br />9898 <br />0063 <br />0900 <br />113500 <br />57500 <br />57500 <br />52000 <br />36500 <br />1000 <br />0 <br />0 <br />0.40 <br />4.78 <br />17.14 <br />5.69 <br />5.63 <br />13.93 <br />1.39 <br />13.93 <br />454 <br />2749 <br />9856 <br />2959 <br />2055 <br />139 <br />0 <br />0 <br />-2185 <br />-441 <br />95 <br />1 <br />Minimum <br />Premium $ <br />Premium Adjustment Period: <br />n Annual; Semiannual; <br />.6400 <br />700 <br />Deposit <br />Premium $ <br />Quarterly; Monthly <br />3920 <br />Page 106 <br />Total Estimated <br />Annual Premium $ <br />15681 <br />Authorized Representative <br />