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r <br />League of Minnesota Cities insurance Trust <br />Group Self-Insured Workers' Compensation Plan <br />Administrator <br />Berkley Administrators <br />145 University Avenue West SL Paul, MN 55103-2044 Phone (612) 281-2100 <br />Notice of Premium Options for Standard Premiums of $25,000 - $50,000 <br />The‘City* <br />ORGNC-0// <br />'j5-vv'I'5ic-!2 <br />^ mm • • <br />‘J li'- <br />CRYSTAL EAY <br />V i /O i / i <br />Agreement No.: <br />Agreement Period: <br />From: <br />U <br />hN 55552 -:*0-:'0 <br />Enclosed is a quotation for workers' compensation deposit premium. Deductible options are now available in return <br />for a premium credit applied to your estimated standard premium of $ . The deductible will apply <br />1*1 I /Vi * •* J OC'Tf <br />per occurrence to paid medical costs only. There is no aggregate limit. <br />As w alternative, cities with a standard premium in e.xcess of S25,000 may select from several retro-rated premium <br />options. The final net cost under the retro-rated option equals the audited standard premium times the minimum <br />factor plus losses and all loss-related costs, not to exceed the audited standard premium times the maximum factor. <br />The net cost for each retro option based on your estimated payroll, would be between the minimum and maximum <br />amounts shown below, depending upon your losses. Adjustments will be made approximately six months after the <br />close of your agreement year and annually thereafter until all claims are closed. These adjustments will be based <br />on audited payroll amounts and reserved as well as paid losses. <br />Ple^e indicate below the premium option you wish to select. You may choose only one, and you cannot change <br />options during the agreement period. <br />OPTIONS <br />1 Regular Premium Option <br />NET DEPOSIT PREMIUM <br />Deductible Options:5a4Hi . <br />j <br />4 <br />5 <br />6 <br />7 <br />□□□□□□ <br />Deductible Premium Credit <br />ner Occurrence Credit Amount <br />$250 3%5ii. <br />500 4.5%1591.55150 <br />1,000 6%175£.54719 <br />2,500 10%5369.55572 <br />5,000 13.5%3675.MB • mm <br />10,000 18%5165.51576 <br />Retrospectively Rated Premium Options: <br />Retro-Rated Est. ftlinimum <br />Minimum Factor Premium <br />8 D 85.4% 5A505. <br />9 □ 79.4% <br />10 □ 68.8% <br />55751. <br />197A0. <br />Maximum <br />Factor <br />115% <br />125% <br />150% <br />Est. Maximum (See"l above <br />Premium for net deposit <br />3£99i. premium) <br />55665. <br />45056. <br />This should be signed by an authorized representative of the city requesting coverage. One of the above options must <br />be selected. Please return a signed copy of this notice to us with payment and make checks payable to the LMCIT. <br />L /f'f. --------- <br />TideTiUe / Date ^ignature Tide / Date <br />For more information on the premium options that apply to your city, refer to the enclosed brochures. <br />LM4502(8/y7)