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League of Minnesota Cities Insurance Trust <br /> Group Self-Insured Workers' Compensation Plan ,' rl'e <br /> ADMINISTRATOR <br /> • EMPLOYEE BENEFIT ADMINISTRATION 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 /> STATEMENT <br /> Deposit Premium for participation in the League of Minnesota Cities <br /> Self-Insured Workers ' Compensation Program. <br /> For the period 06-01-89 to 06-01-90 $ 33,834.60 <br /> 4th Quarterly Payment $ 15,782.25 <br /> Retro Adjustment 22,915.00 <br /> Payment Received (Liquor St.) ( 4,862.65) <br /> Total Due $ 33,834.60 <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 <br /> P.O. BOX 59143 <br /> MINNEAPOLIS. MINNESOTA 55459-0143 <br /> Phone(612)544-0311 <br /> j: <br /> [a HT <br /> ` . <br /> • d I r <br /> r•S' <br /> EBA 444 (9/86) Self-funded Workers'Compensation Specialists <br />