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I.eague of Minnesota Cities Insurance Trust JAN 26'90 <br /> Group Self-Insured %Vorkcrs Compensation Plan RL <br /> Arm--4iST PA TOR <br /> EMPLOYEE BENEFIT ADIIINISTRATION CO. <br /> 8441 Wayzata Blvd. Suite 200 P.O. Box 59143 Minneapolis, Minnesota 55459-0143 Phone(612) 544-0311 <br /> 02-468 <br /> To: City of St. Anthony <br /> 3301 Silver Lake Road <br /> Minneapolis , MN 55418 <br /> S T A T E M E N T <br /> Deposit Premium for participation in the League of Minnesota Cities <br /> Self-Insured Workers ' Compensation Program. <br /> For the period 06-01-90 to 06-01-91 $ 23,017.75* <br /> 1st Quarterly Payment Due <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 / (4U 02 <br /> P.O. BOX 59143 <br /> MINNEAPOLIS. MINNESOTA 55459-0143 <br /> Phone(612)544.0311 <br /> 19i <br /> �g� 017.,5 <br /> nr-ri nir,I <br /> ESA 444 (9/86) Sell-funded Workers' Compensation Specialists <br />