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League ot hnlnnesota cities Insurance i rust <br /> Group Self-insured Workers' Compensation Plan <br /> AClr~m~tcato~ <br /> Berkley Administrators <br /> ~ · merr~e~ of the berkley Risk Management Services Group <br />P.O. IBox 59143 Minneapolis, MN 55459-0143 Phone (612) 544-031 <br /> <br />FOR I~rM','I)ARD PREMrUM~ OF $50,000 -- $]50,00O <br /> <br /> Agroomenl NO.: '3~-(i'5031 I- 1 1 <br />Agreemen! Penod: <br /> From: 0', ,'0! .' I ~.h <br /> 7o: .-31 ./01 ...'1 995 <br /> <br />Enclosed is a quotation for workers' compensation deport premium. Deductible options are now available in return for <br />a premium credit apphed[m your estimated standard premium of $ .57'¢7.:. Tn· deductible will apply per <br />occurrence to paid medidgl costs 0nly. Tn·re is no aggregam limit. <br /> <br />As an alternative, cities w/kb a standard premium in excess of $25,000 rna), select from several retro-rated premium opt/om. <br />The final net cost under ~e retro-rated option equals the audited standard premium times the minimum factor plus loss,es <br />and all loss-related costs, ~not to exceed the audited standard premium times the maximum factor. Tn· net cost for e~ch <br />rerro opt/on based on yoCr estimated payroll, would be between the minimum and max/mum mounts shown below, <br />depending upon your losses. Adjustments will be made six months after the close of your agr~ment ?ear and annually <br />thereafter until all claims ~re clo~:l. Tn·se adjustments will be based on audited payroll amounts an~t reserved as well <br />as paid losses. <br /> <br />Please indicate below the Premium option you wish to sel~t. You may choose only one and you cannot change options <br />dunng the agreement period. <br /> <br />OPTIONS <br /> <br />NrET DEPOSIT PRE_MJL~'[ <br /> <br />] [] Regular Pi-~mi,,m Option <br /> Deductible Options: <br /> <br /> Deductible Premium Credit <br /> per Oecu;rmnee Credit Amount <br />2 ~ $%{0 2% i :~.. <br />3 [] 500 4 % ~.=._'v:~. <br /> <br />5 ~. 2.500 9% <br />6 5,0(0 12% <br />7 [] 10,000 17% <br /> <br /> ReTrospectively R~zed Premium Options: <br /> Retro-R~ted Minimnm M~'imnm NL~,xdmum <br /> Minimum_ Factor Pr·minim Factor Premium <br />8 [] 52.9~% 130% <br />9 [] 49.9.% 3o,:)q.s. 140% <br /> · -s .,-,~_ 150% <br />10 [] 47.3% '--'?' =' <br /> <br />(S~ #i above <br />for net deposit <br />premium) <br /> <br />'I-ds should be si~ed by tm authorized repres~tztive of the city. requ~ing coverage. One of the above options must <br />~ s?ected. ?lease return a signed copy of this notice to the Admirfis~or with payrnent and make chec~ payable to <br /> <br />~r"d~- ~ T~ti~c,/ Date <br /> <br />For more information on ithe premium options that apply to your city, refer to the enclosed brochures. <br /> BA 4503CG (4/93) <br /> <br /> <br />