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FROM : MUCIQ FOX NO. : 18O02S78G71 O«o. 15 2003 12:07PM P3 <br />Minnesota Workers' Compensation <br />insurers Associauon. Inc <br />7701 France Avenue South - Suite 450 <br />Minneapolis. MN 56435-3200 <br />Quamy aravMer e< MermttkM a Services <br />aru: 3134695 <br />NOTE TO SrCRVICINO CONTHACTORi <br />According to our rocorda« uho oirployor should bo cleseifl^d as shown: <br />COOE PAYROLL RATE <br />3083 18000 2.51 <br />PSEMTUK <br />4S2 <br />Total Pramixirnt <br />Merit Rating: <br />Standard Pre.-nium: <br />expense Constant: <br />Terrorism Coverage: <br />Totol Eotimoted Actual Prcniium: <br />SCP Assessment! <br />Policy Total Estimated Cost) <br />Deposit Framium: <br />S452.09 <br />.67 <br />303.00 <br />5145.00 <br />94.00 <br />$452.00 <br />$19.00 <br />5470.00 <br />3470.CO <br />Enclosed is the Agency Check in the amount of $563.76 endorsed payable to <br />your company, along with the application for coverage. <br />We suggest that the policy provide for annual premium adjusr.’nenta. <br />Enc. <br />IN ACCORDANCE WITH M.S. 79.211, DIVISION Of PAYROLL A.MONG THE CLASSES <br />LISTED ABOVE WILL BE ALLOWED ONLY IF THE EMFLOYE.H'S RECORDS PROVIDE <br />ADEQUATE SUPPORT FOR SUCH DIVI.SICN. <br />Employer Namea Included: <br />POM TRUST 5040 ENC.HANTED 3LVD MOUND MN 55364 <br />NAVARRE LANES 5040 ENCHANTED BLVD <br />Please refer to the following when responding: 100342338