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League of Minnesota Cities Insurance Trust <br />Group Self-Insured Workers* Compensation Plan <br />145 University Avenue West St Paul. MN 55103-2044 Phone (651) 215-4173 <br />Self-Insured Workers’ Compensation Quotation <br />(RENEWAL of Agreement No. 0E-000362-1A) <br />DRONC <br />01/01/SOOO 01/01/2001 <br />STREET CONSTRUCTION L MAINTENANCE <br />WATERWORKS <br />POLICE <br />CLERICAL <br />POLICE RESERVES <br />MUNICIPAL EMPLOYEES <br />ELECTED OR APPOINTED OFFICIALS <br />ANIMAL CONTROL <br />CLUB-COUNTRY/GOLF <br />CODE RATE <br />ESTIMATED <br />PAYROLL <br />DEPOSIT <br />PREMIUM <br />5506 4.00 30400u.12160. <br />7520 2.81 40000.1124. <br />7720 2.74 902000.24715. <br />8810 0.43 346500.1490. <br />7722 3.42 41300.1412. <br />9^j10 0.86 402000.3457. <br />9411 0.33 18200.60. <br />8831 1.62 30200.489. <br />9060 1.48 72000.1066. <br />Manual Premium 45973. <br />Experience Modification 0.82 <br />Standard Premium <br />Managed Care Credit OK <br />Deductible Credit 0/> <br />Premium Discount <br />Discounted Standard Premium <br />LMC Insurance Trust Discount 0*/. <br />Net Deposit Premium <br />37698. <br />0. <br />0. <br />3106. <br />3A592. <br />0. <br />3A592. <br />The foregoing 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 />LMCrr 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 581517 <br />Minneapolis, MN 55458-1517 <br />LM 4410(8/99) <br />I