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League of Minnesota Cities Insurance Trust <br /> Group Self-Insured Workers' Compensation Plan JUN u 2 1989 <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 /> To: City of St. Anthony <br /> 3301 Silver Lake Road <br /> Minnepaolis, MN 55418 <br /> STATEMENT <br /> Deposit Premium for participation in• the League of Minnesota Cities <br /> Self-Insured Workers ' Compensation Program. <br /> For the period 6-1-89 to 6-1-90 $ 63, 129.00 <br /> One quarter down payment due 6-1-89 $ 15,782.25 <br /> • <br /> Remittances should be made payable to the LEAGUE OF MINNESOTA CITIES <br /> INSURANCE TRUST and mailed on or before the effective date of your <br /> coverage to: <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 /> P <br /> RETAIN THIS COPY <br /> • <br /> WITH YOUR P <br /> EBA 444 (9/86) Self-Funded Workers'Compensation Specialists <br />