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League of Minnesota Cities Insurance Trust <br /> Group Self-insured Workers' C, ompensat~on Plan <br /> <br /> AO~mltretor <br /> Berktey Administrators <br /> a metl~ber of the Berkte¥ Risk Management Services Group <br />P.O. Box 59143 Minneapolis, MN 55459-0143 Pl~one (612) <br /> <br />Self-Insured Worker~' Compensation Quotalion <br /> <br />544-0311 <br /> <br />STF,:~-E7 COi';STF:UCT.~ON ~, MA,]fJTENANC£ <br />WATE. RWDRKS <br /> <br />POLICE <br />SLE R ~ CAL <br />· '-,,-,iL.~]h~ ,MAINTENAIqCE c-: F',EF';~}F: <br /> <br />F'AF:I <br />.r'~LIH'-' C ~ PAL EHPLDYEES <br />E~ECTED DF: ~F'F'DINTED OFF~C.[ALS <br /> <br />CODE RATE <br /> <br />DEF'OS} T <br />F'F,'EM i LIM <br /> <br />51977. <br /> <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 />wilJ be su~ect to revisions in rates, payrolls and experience modification. '¢,rnlle you are a member of <br />the LMCIT Workers' Compensation Plan, you will be eligible to pm,-dcipate in diSLr-ibudons from the <br />Trust based upon claims experience and earnings of the Trust. <br /> <br />If you desire the coverage offered above, pl~se 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, Bertdey AdmLnistrators. <br /> <br />BA 441CG (12/92) <br /> <br /> <br />