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League of Minnesota Cities Insurance Trust <br /> Group Self-Insured Workers' Compensation Plan <br /> Administrator <br /> Berkley Administrators <br /> a member of the Berkley Risk Management Services Group • <br /> P.O. Box 59143 Minneapolis, MN 55459-0143 Phone (612) 544-0311 <br /> NOTICE OF PRENIiUAl OPTIONS <br /> FOR STANDARD PRENIIUNIS OF$50.000—$150,000 <br /> The 'City" Agreement No.: 66-S <br /> Agreement Period: <br /> ti T ANTH0,NY From: ;.J 6 -•11, 1'7'' <br /> To: J , . 1 <br /> Enclosed is a quotation for workers' compensation deposit premium. Deductible options are now available in return for <br /> a premium credit applied to your estimated standard premium of$ 12�;�J4, The deductible will apply per <br /> occurrence to paid medical costs only. There is no aggregate limit. <br /> A s an alternative,cities with a standard premium in excess of$25,000 may select from several retro-rated premium options. <br /> The final net cost under the retro-rated option equals the audited standard premium times the minimum factor plus losses <br /> and all loss-related costs, not to exceed the audited standard premium times the maximum factor. The net cost for each <br /> retro option based on your estimated payroll, would be between the minimum and maximum amounts shown below, <br /> depending upon your losses. Adjustments will be made, based on audited payroll amounts, six months after the close <br /> of your agreement year and annually thereafter until all claims are closed. <br /> Please indicate below the premium option you wish to select. You may choose only one and you cannot change options <br /> during the agreement period. <br /> ❑ Regular Premium Option <br /> Deductible Options: <br /> Deductible Premium Credit <br /> per Occurrence Credit Amount <br /> ❑ $250 2% 2413. <br /> ❑ 500 4% 4827. <br /> ❑ 1,000 5% 6034. <br /> ❑ 2,500 9% 10861 . <br /> ❑❑ 10,E 17% 24515. <br /> Retrospectively Rated Premium Options: <br /> Retro-Rated Minimum Maximum Maximum <br /> Minimum Factor Premium Factor Premium <br /> ❑ 52.9% 63,937. 130% 1 516376" <br /> ❑ 49.9% 140% 1"3044 <br /> `"��"1`'' I50% <br /> ❑ 47.3% 57079. 131011 . <br /> In order to issue your workers'compensation agreement,one of the above options must be selected. Please return a signed <br /> copy of this notice to the Administrator. The city will be billed for the premium. <br /> 0 <br /> Signature Title Date <br /> For more information on the premium options that apply to your city, refer to the enclosed brochures. <br /> BA 4503CG (12/92) • <br />