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CITY OF MOUNDS VIEW <br />WORKERS' COMPEISATION • <br />1. Statutory coverage - Minnesota <br />2. Employers' Liability - Coverage B limit: $100,000 <br />3. Required Endorsements: <br />(a) All states <br />(b) Voluntary compensation - all employees all states <br />State of hire benefits <br />(c) Elected or appointed officials <br />(d) Volunteer workers �8 <br />4. Quotations are to be based on an experience modification factor of <br />5. Guaranteed Cost Plan: <br />(a) Show advance premium discount <br />(b) Dividend factor <br />(c) Net cost <br />6. Alternative Quote: <br />(a) Other participation or dividend plans <br />7. See attachment for breakdown on projected payrolls. Note, the attached <br />estimated 1984-1985 payrolls have had all applicable deductions taken; <br />use only the payroll figures as shown. <br />• <br />