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<br />League of Minnesota Cities Insurance Trust
<br />Group Self-Insured Workers' Com~ensation Plan
<br />
<br />145 University Avenue West St. Paul, MN 55103-2044 Phone (651)215-4173
<br />
<br />Statement of Premium Audit Adjustment
<br />
<br />MAY 1 2 2003
<br />
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<br />
<br />1. The "City"
<br />CENTER VILLE, CITY 0 F
<br />1880 MAIN STREET
<br />CENTER VILLE MN 55038
<br />
<br />Agreement No.: 0200039617
<br />Agreement Period From: 3/01/2002
<br />To: 3/01/2003
<br />
<br />Audited Annual
<br />Remuneration
<br />
<br />Rates
<br />Per $100 of
<br />Remuneration
<br />
<br />Code
<br />No.
<br />
<br />Classifica tion
<br />
<br />Audited
<br />Premium
<br />
<br />$
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<br />SEE ATTACHED SCHEDULE FOR DETAILS
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<br />
<br />1.26
<br />
<br />6961.
<br />1810.
<br />8771.
<br />
<br />Manual Premium
<br />Experience Modification
<br />Standard Premium
<br />Managed Care Credit
<br />Deductible Credit
<br />Premium Discount
<br />Net Acutual Premium
<br />Less Deposit Premium
<br />Balance Due City
<br />
<br />0%
<br />.0 %
<br />
<br />358.
<br />8413.
<br />10431~
<br />C 2018)
<br />
<br />The foregoing statement is for the year end adjustment to your workers' compensation deposit premium. It was prepared after an
<br />audit of your payroll records and a final determination of your experience modification factor for the period indicated above.
<br />If the final balance shown is due to your city, a check will be issued separately. If the final balance is due to the LM CIT ,
<br />please forward your remittance, payable to the LMC Insurance Trust, to the administrator at the address indicated above.
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<br />410972536 40.36-
<br />BEULKE AGENCY
<br />4782 W ASHINGTON AVE
<br />WHITE BEAR LAKE MN 55110
<br />
<br />Agent:
<br />00489
<br />
<br />, ~
<br />
<br />i--'
<br />
<br />5/08/2003
<br />
<br />LM 4460(8/99)
<br />
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