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League of Minnesota Cities Insurance Trust <br /> Group Self-insured Workers' Compensation Plan <br /> • ADMINISTRATOR <br /> EMPLOYEE BENEFIT ADMINISTRATION CO. <br /> • 8441 Wayzata Blvd. Suite 200 Minneapolis, Minnesota 55426-1392 Phone(612)544-0311 <br /> Self-Insured Workers' Compensation Quotation <br /> Name of City: 71 7 i ST <br /> H-D tTv <br /> Policy Period : From: To <br /> Estimated Annual Premium: <br /> it:"­..::..­,; i p cr."i <br /> n i <br /> PUP -.17 <br /> i R , 5 <br /> - 07 VD; Uc nj T E <br /> _P 11 4' z <br /> W <br /> J!, <br /> 4 <br /> 1"U L 1_1% I G NrIll 1% Ji <br /> r. tir c:P7c:­T <br /> I in <br /> • f-T <br /> J—1, <br /> I I U F, D a Js <br /> t4 <br /> d <br /> iE <br /> ill i."iii <br /> 0 L!Tl t C'2 Tj 0 -,1 L.:7 <br /> L J.' <br /> F <br /> The foregoing quotation is for a deposit premium based on your <br /> estimate of payroll . Your final actual premium will be computed after <br /> an audit of payroll subsequent to t'he close of your policy year and <br /> will be subject to revisions in rate or experience modification. <br /> While you are a member of the LMCIT Workers' Compensation Plan, you <br /> will be, eligible to participate in distributions from the Trust based <br /> upon cla'ims experience and earnings of the Trust . <br /> Employee Benefit Administration Co. <br /> EBA 441 CG (11/87) <br />