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City Employees: Please indicate the estimated payroll for City employees for the coming policy year. The payroll descriptions and <br /> codes provided are the most commonly used. If you need to add additional payroll descriptions, please use the blank spaces and the <br /> codes on the attached List. <br /> k, holiday, and vacation pay should be included in the payroll totals. Do not reduce payrolls for sick, holiday, and vacation pay. <br /> Does your City have a flexible benefits plan such as a cafeteria plan, Section 125 plan, or flexible reimbursement account plan? <br /> Yes x No <br /> Employee contributions to a flexible benefits plan should be included in the payroll figures you provide. City contributions should <br /> not be included. (This is similar to how these plans are treated under PERA.) <br /> Payroll Description Code Amount Payroll Description Code Amount <br /> Ambulance Services (Not <br /> Volunteer) 7380 $ Sewage Plan 7580 $ <br /> Ambulance Services (Volunteer) 7381 $ <br /> Off Sale Liquor Store 8017 $ <br /> Building Operations 9015 $ Street-wnd-R-easl-Cencssuction General PW 5506 $ 153,916.55 <br /> City Shop and Yard 8227 $ Waterworks 7520 $ 39.236.79 <br /> Clerical Office 8810 $ 272,103.78 Other: $ <br /> Electric and Steam Power 7539 $ Other: City Hall 9015$ 8,197.28 <br /> Firefighters (Not Volunteer) 7706 $ Other: $ <br /> Firefighters (Volunteer) 7708 pop Other: Rink Attendant 9016 $ 3,000.00 <br /> Building Inspector 9410 $ 51,205.75 Other: $ <br /> Parks 9102 $ 26 871 78 other: Cable 7610 $ 9,519.12 <br /> Police 7720 $ Other: $ <br /> Restaurant and Bars (on sale) 9084 $ Other: $ <br /> PREMIUM OPTIONS <br /> Please select the premium options below in which the City is most interested. All of the premium options selected will be quoted to <br /> however, only one premium option can be ultimately assigned for the coming plan year. <br /> Regular Premium Option: Please indicate if the City would be interested in the regular premium option. Yes x No <br /> Deductible Options: Please Indicate the deductible level and associated premium discount the City would like to consider. <br /> Deductible Premium Credit • <br /> $250 1.50% <br /> $500 2.50% <br /> $1,000 4.50% <br /> $2,500 7.50% <br /> $5,000 11.00% <br /> $10,000 15.00% • <br /> Retrospective Rating: Please indicate if the City would be interested in retrospective rating (if applicable). Yes No x <br /> Managed Care Option: Please indicate if the City participates in a state - certified managed care organization (M CO) for workers' <br /> compensation benefits, and if so, the name of that organization. Yes No x (please note: there is no longer a premium <br /> credit for enrolling with a MCO) <br /> MCO: <br /> Contact Information: Please provide us with a contact for questions about the City's workers' compensation coverage. <br /> City Contact Person Mike Jeziorski Phone 651 -429 -3232 Email mjeziorski @centervillemn.com <br /> Please fax this completed form to the League of Minnesota Cities Insurance Trust at 651 -281 -1298. <br /> If you have any questions, please contact Barb Meyer, Underwriting Technician, by phone at 651- 215 -4173 or 800- 925 -1122, or via <br /> email at bmeyer @lmc.org. <br /> LM4684 (01 /11) <br /> 23 <br />