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League of Minnesota Cities Insurance Trust <br />Group Self-Insured Workers ’ Compensation Plan <br />145 University Avenue WSst St. Paul, MN 55103-2044 Phone (051) 215-4173 <br />Self-Insured Workers ’ Compensation Quotation <br />(RENEUAL of Agreement No. 0S-00036S-16) <br />ORQNO, CITY OF <br />01/01/S0O2 01/01/2003 <br />STREET CONSTRUCTION & MAINTENANCE <br />UATERUORKS <br />POLICE <br />CLERICAL <br />MUNICIPAL EMPLOYEES <br />ELECTED OR APPOINTED OFFICIALS <br />ANIMAL CONTROL <br />CLUB-COUNTRY/COLF <br />ESTIMATED DEPOSIT <br />CODE RATE PAYROLL PREMIUM <br />5506 “.40 359600.15822. <br />7520 2.41 45100.1087. <br />7720 3.01 1032700.31084. <br />8010 42 418900.1759. <br />9A10 1.08 484500.5233. <br />9A11 0.40 18200.73. <br />8831 2.00 36900.768. <br />9060 1.48 78800.1166. <br />Manual Premium 56992. <br />Experience Modification 1.13 <br />Standard Premium 64401. <br />Managed1 Care Credit 0%0. <br />Deductible Credit ov:0. <br />Premium 1Discount 5643. <br />Discounted Standard Premiufl.58758. <br />: Insurance Trust Discount 0'/.0. <br />Net Deposit Premium 58758. <br />The fcregoing 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 will <br />be subject to revisions in rates, payrolls and experience modification. While you are a member of the <br />LMCIT Workers ’ Compensation Plan, you will be eligible to participate in distributions from the Trust <br />based upon claims experience and earnings of the Trust <br />If you desire the coverage offered above, please complete the enclosed “Notice of Premium Options ” and <br />return it and your check for the deposit premium (made payable to the LMCIT) to: <br />Berkley Risk Administrators Company, LLC <br />PO Box 581S17 <br />Minneapolis, MN 55458-1517 <br />LM 4410 (8/99)