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League of Minnesota Cities Insurance Trust <br /> Group Self-Insured Workers'Compensation Plan <br /> WORKERS'COMPENSATION AND EMPLOYERS'UAB0M AGREEMENT <br /> AOMINISTMTOR <br /> EMPLOYEE BENEFIT ADMINISTRATION CO. <br /> • 8441 Wayzata Blvd. Suite 200 P.O. Box 59143 Minneapolis, Minnesota 55459-0143 Phone(612)544-0311 <br /> STATEMENT OF PREMIUM AUDIT ADJUSTMENT <br /> The"City" Agreement No. 02-000468-3 <br /> CITY OF ST ANTHONY Agreement Period: From 06/01/1988 <br /> To 06/01/1989 <br /> 3301 SILVER LAKE ROAD <br /> MINNEAPOLIS MN 55418 <br /> AUDITED ANNUAL RATES CODE CLASSIFICATION AUDITED <br /> REMUNERATION PER SWOOF NO. PREMIUM <br /> REMUNERATION <br /> 210455. 4.17 7706 FIREFIGHTERS (NOT VOLUNTEER) 8776• <br /> 25155. 5.88 9410 MUNICIPAL EMPLOYEES 1479. <br /> 29021 . 4.13 9102 PARKS 1199. <br /> 138570. 8.33 5506 STREET CONSTRUCTION & MAINTENANCE 11543. <br /> 197734. 0.36 8810 CLERICAL 712• <br /> 200101. 1 .69 8017 OFF SALE LIQUOR STORE 33B2. <br /> 193000. 2.85 9079 ON SALE LIQUOR STORE 5501 . <br /> 96989. 3.11 7520 WATERWORKS 3016. <br /> 400837. 5.99 7720 POLICE 24010. <br /> • 10934. 5.86 9015 BUILDING MAINTENANCE & REPAIR 641 . <br /> 45695. 9.08 9402 STREET CLEAN/SEWER CLEAN/SNOW REMOVAL 4149. <br /> 23242. 4.82 8227 CITY SHOP & YARD 1120. <br /> 1571733. <br /> Manual Premium 65528. <br /> Experience Modification 1.21 <br /> Standard Premium 79289. <br /> Premium Discount 7057. <br /> Discounted Standard Premium 72232. <br /> LMC Insurance Trust Discount ,0% 0. <br /> Net Actual Premium 72232. <br /> Less Deposit Premium 68951.00 <br /> Balance Due LMC Trust 3281.00 <br /> The foregoing statement is for the year end adjustment to your workers'compensation deposit premium.It was prepared after an audit of your payroll records and a final determination <br /> of your experience modification factor for the period indicated above.If the final balance shown is due to your city a cheek will accompany this form.N the final balance shown is due <br />to <br /> the LMCIT please forward your remittance,payable to the LMC Insurance Trust,to the administrator at the address indicated above. <br /> Agent <br /> F-411546732 0.00 <br /> • CORPORATE RESOURCES <br /> 1401 W 76TH ST #100 <br /> MINNEAPOLIS, MN 55423 <br /> 75664.00 6713.00 0.00 3625.00 344.00 0.00 3281 .00 <br /> EBA 446 CG(11/87) /D AIN: 1. .00 <br />