Laserfiche WebLink
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 /> Self-Insured Workers' Compensation Ouotation <br /> 4L�� -7 i t G .LV ` '-i i V. _ <br /> ST 1 <br /> ANTHONY <br /> EST 1 t,A i ED DEPOS 1 t <br /> L. TE PAv <br /> [:L?L: P;i-i C N c P;0 LL Ph`EH, <br /> SEE ATTACHED SCHEDULE FOR DETHPILS <br /> Manual Premium 1ED 3140 <br /> Experience Modirication 1 .1 <br /> Standard Fief+iLUD 1270 6'!4. <br /> Managed Care Credit ;. '. 0, <br /> Deductible Credit QA !?. <br /> Premium Di_cc<t_T-1t 11485. <br /> Discounted Staff d-ard PremiUM 1t>9189. <br /> LMC InsUrance Trust DiSCOW-ft ail. 0 <br /> Net Deposit Pr emiUffl 109169. <br /> The foregoing quotation is for a deposit premium based on your estimate of payroll. Your final actual <br /> premium will be computed after an audit of payroll subsequent to the close of your agreement year and <br /> will be subject to revisions in rates, payrolls and experience modification. While you are a member of <br /> the LMCIT Workers' Compensation Plan, you will be eligible to participate in distributions from the <br /> Trust based upon claims experience and earnings of the Trust. <br /> If you desire the coverage offered above, please complete the enclosed "Application for Coverage" and <br /> return it and your check for the deposit premium (made payable to the LMC Insurance Trust) to the Plan <br /> Administrator, Berkley Administrators. <br /> BA 441 CG (12/92) <br />