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League of Minnesota Cities Insurance Trust <br />Group Self-Insured Workers' Compensation Plan <br />Administrator <br />Berkley Administrators <br />amembarofth* Berkley Risk Management Services Group <br />P.O. Box 59143 Minneapolis, MN 55459-0143 Phone (612)544-0311 <br />Self-Insured Workers*Comoensation Quotation <br />(RENEWAL of Agreement No. OS-000362-11) <br />ORONG <br />01/01/1997 01/01/1998 <br />• <br />ESTIMATED DEPOSIT <br />CODE RATE PAYROLL PREMIUM <br />STREET CONSTRUCTION L MAINTENANCE 5506 4.62 243700.11259. <br />WATERWORKS 7520 3.67 50400.1850.POLICE 7720 3.36 757400.25449. <br />CLERICAL 8810 0.42 328300.1379. <br />MUNICIPAL EMPLOYEES 9410 1.19 34430c.4097. <br />ELECTED OR APPOINTED OFFICIALS 9411 0.45 18200.82.ANIMAL CONTROL 8331 . 1.77 10900.193. <br />CLUB-COUNTRY/GOLF 9060 2.04 60800.1240. <br />%Manual Premium 45549. <br />Experience Modification 0.7l <br />Standard Premium 323h0. <br />Managed Care Credit O'A 0. <br />Deductible Credit o:>;0. <br />Premium Discount 2597. <br />Discounted Standard Premium 29743. <br />LMC Insurance Trust Discount 0/0. <br />Net Deposit Premium C * / . W • <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 <br />will be subject to revisions in rates, payrolls and experience modification. \\Tiile you are a member of <br />the LMCIT Workers' Compensation Plan, you will be eligible to participate in distributions from the <br />Trust based upon claims experience and earnings of the Trust. <br />If you desire the coverage offered above, please complete the enclosed "Application for Coverage" and <br />return it and your check for the deposit premium (made payable to the LMC Insurance Trust) to the Plan <br />Administrator, Berkley Administrators. <br />BA441CG (12/92)