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League of Minnesota Cities Insurance Trust <br /> Group Self-Insured Workers' Compensation Plan <br /> AnMINISTRATOR <br /> EMPLOYEE BENEFIT ADMINISTRATION CO. <br /> 8441 Wayzata Blvd. Suite 200 P.O. Box 59143 Minneapolis, Minnesota 55459-0143 Phone(612)544-0311 <br /> Application for Coverage <br /> (RENEWAL of Agreement No. 02-00046-2-3) <br /> The City of ST ANTHONY Minn. <br /> hereby requests coverage under the League of Minnesota Cities Self-Insured Workers' <br /> Compensation Program for the period to <br /> 06,101/1969 0S;01!1990 <br /> and agrees to pay a deposit premium of$ <br /> b3, 129.0V <br /> One copy of this application should be signed by an authorized representative of the city requesting <br /> coverage and returned to the program administrator: <br /> EMPLOYEE BENEFIT ADMINISTRATION CO. <br /> 8441 WAYZATA BLVD. SUITE 200 <br /> P.O. BOX 59143 <br /> MINNEAPOLIS, MINNESOTA 55459-0143 <br /> Phone(612)544-0311 <br /> Signature Title <br /> Date <br /> EBA 442 CG (11/87) • <br />