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League of Minnesota Cities Insurance Trust <br /> Group Self-Insured Workers'Compensation Plan <br /> YMAV"65COMPENSATION ANO EMPL(n'06'LL&SKM AC.WMEHF <br /> AOkR111616TRATOR <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••Cit,•• Agreement No. 02-000468-4 <br /> ST ANTHONY Agreement Period: From 06/01/1989 <br /> To 06/01/1990 <br /> 3301 SILVER LAKE ROAD <br /> MINNEAPOLIS MN 55418 <br /> AUDITED ANNUAL RATES CODE CLASSIFICATION AUDITED <br /> REMUNERATION PER S100 OF NO. PREMIUM <br /> REMUNERATION <br /> 135202. 8.10 5506 STREET CONSTRUCTION u MAINTENANCE 10951. <br /> 84458. 3.23 7520 WATERWORKS 2728. <br /> 215004. 9.41 7706 FIREFIGHTERS (NOT VOLUNTEER) 20232. <br /> 412149. 4.54 7720 POLICE 18712. <br /> 202402. 2.46 8017 OFF SALE LIQUOR STORE 4979. <br /> 26024. 3.88 8227 CITY SHOP & YARD 1010. <br /> 186692. 0.39 8810 CLERICAL 728. <br /> 9193. 9.95 9015 BUILDING MAINTENANCE 6 REPAIR 915. <br /> 206101. 3.70 9079 ON SALE LIQUOR STORE 7626. <br /> 28223. 5.02 9102 PARKS 1417. <br /> 39451. 6.08 9402 STREET CLEAN/SEWER CLEAN/SNOW REMOVAL 2399. <br /> 20459. 2.91 9410 MUNICIPAL EMPLOYEES 595. <br /> 15876. 2.91 9411 ELECTED OR APPOINTED OFFICIALS 462.• <br /> 20408. 4.54 7720 POLICE RESERVES 927. <br /> ------------ <br /> 1601642. <br /> Manual Premium 73681. <br /> Experience Modification 0.95 <br /> Standard Premium 69997. <br /> Premium -Discount 6175. <br /> Discounted Standard Premium 63822. <br /> LMC Insurance Trust Discount 0% 0. <br /> Net Actual Premium 63822. <br /> Less Deposit Premium 63129.00 <br /> Balance Due LMC Trust 693.00 <br /> a <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 check will accompany this form.If the final balance shown is due 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 /> • <br /> 69231.-00--' -- " 6102.00 '--'0.00"- 766.-00 -73:00- - 0'.00 ' --' -693.00 <br /> EBA 446 CG(11/87) I . <br />