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League of Minnesota Cities Insurance Trust Croup Self-Insured Workers' Compensation Plan ADMINISTRATOR EMPLOYEE BENEFIT ADMINISTRATION CO. 8441 Wayzata Blvd. Suite 200 Minneapolis. Minnesota 55426-1392 Phone (612) 544-0311 • Notice of Premium Refund Option At the end of each year (January 1) of the League of Minnesota Cities Insurance Trust Self-Insured Workers ' Compensation Program a distribution of excess surplus funds , if any, will be returned to participants under a formula taking into account the earnings and claims experience of the Trust , as well as the loss records of individual participants. As an alternative, participating cities with a discounted standard premium in excess of $50 ,000 may elect to have their distribution made to them in an amount determined by their individual loss experience . The final net cost to an electing participant will be as follows : Discounted standard premium x 35% plus losses x 1 .10 equals minimum final net cost . Maximum final net cost will not exceed standard premium x 1 .20 . Please return a signed copy of this notice to the administrator with your application for coverage. If this election is made the final net cost of your workers ' compensation insurance for the coming policy year, based on estimated payroll , would be between a minimum of $ 24, 133 and a maximum of $ 90,797 depending upon your losses . Adjustments will be made six months after the close of your policy year and annually thereafter. If this election is not made you will share in the distribution of surplus funds. Yes, we wish to select the Alternative Refund Option . Policy Period : Name of City St. Anthony 6-1-88 to 6-1-89 By: Title: Date: This election cannot be accepted unless received in the offices of the plan administrator by the beginning of your policy period. Sell-Funded Insurance Specialists EBA 450(10/87)