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League of Minnesota Cities Insurance Trust <br /> Group Self- Insured Workers' Compensation Plan <br /> 145 University Avenue West <br /> St. Paul, MN 55103 -2044 <br /> RENEWAL DATA <br /> The "City :" <br /> CENTERVILLE, CITY OF Agreement No.: 0200039626 <br /> 1880 MAIN STREET Quote To: <br /> CENTERVILLE MN 55038- Quote Due On: 2/01/12 <br /> Agreement Expires: 3/01/12 <br /> Your coverage under the LMCIT Self - Insured Workers' Compensation program will expire soon. This Renewal Data sheet will be <br /> used to generate a premium quote for the different workers' compensation plans available. A copy of the City's previous year's <br /> selected coverages and premiums is attached for your reference. <br /> Coverage Options <br /> All of the options available to the City are outlined below, and described in the accompanying memo, Things to Think About When <br /> Renewing Your City's Workers' Compensation Coverage. You can select any coverage options in which the City may be interested. <br /> Premium quotes for all coverage options will be provided, and a final coverage decision can be made at the time you receive the <br /> complete quote. <br /> Elected Officials: Please indicate if the City would be interested in covering elected officials. Yes x No <br /> If yes, please list the estimated annual payroll for all elected officials the City would like to cover under workers' compensation. <br /> The 2012 premium rate for mayors and council members is $ .24 per $100 of payroll. This rate is applied to the greater of either <br /> the official's actual salary or an imputed salary of $70 per week. Note: Coverage for elected officials requires a resolution passed <br /> by the City Council. <br /> Payroll Description Code Amount <br /> 41 0 00 fi <br /> Elected Officials 9411 $ 27,900 <br /> Members of Separate Administrative Boards: Please indicate if the City would be interested in covering members of separate <br /> administrative boards. Yes x No <br /> If yes, please select any separate administrative boards the City would like to cover under workers' compensation. (This coverage <br /> includes Board Members only.) <br /> 1. Utility or utility commission 5. Welfare or public relief agency <br /> 2. Port authority 6. School board <br /> 3. Housing and redevelopment authority 7. Joint powers board <br /> 4. Hospital or nursing home board or commission 8. x Other park and Recreation and Planning and <br /> Zoning Committes <br /> Employees of Separate Administrative Boards: If the City has elected to cover specific Board Members above, the City can also <br /> choose to cover employees of those boards. Please indicate which type of quote the City would like: <br /> x No quote for administrative board employees. <br /> Combined quote to include employees of both the administrative board and the City. <br /> Separate quote for employees of the City and each administrative board selected above. <br /> Volunteers: Attached to this Renewal Data sheet is a memo, Accident Coverage for City Volunteers. If the city would like to cove <br /> City volunteers, not designated as employees, and members of advisory boards and comittees, please review the memo that outlines <br /> the various options. <br /> How does the city obtain a quote? <br /> Please complete the attached application and send to LMCIT. <br /> (over) LM4684 (01/11) <br /> 22 <br />