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League of Minnesota Cities Insurance Trust <br /> Group Seff-Insured Workers' Compensation Plan <br /> Administrator <br /> Berkley Administrators formerty EBA <br /> a member or the Berkley Risk Management Services Group • <br /> P.O. Box 59143 Minneapolis, MN 55459-0143 Phone (612) 544-0311 <br /> REVISED <br /> APPLICATION FOR COVERAGE_ <br /> (RENEWAL of Agreement No. VE-000468-b) <br /> The city of ST ANTHONY Minnesota <br /> hereby requests coverage under the League of Minnesota Cities Self-Insured Workers' <br /> Compensation Plan for the period 06/,0ii iy;a to 06i0ii i� 3 <br /> • <br /> and agrees to pay a deposit premium of S i5,%`f%.015 <br /> One copy of this application should be signed by an authorized representative of the city <br /> requesting coverage and returned to the Plan Administrator. <br /> Signature Title <br /> Date <br /> �1 <br /> R <br /> �- maC A • <br /> Y <br /> P <br /> A <br /> M <br /> BA 442CG (5191) <br />