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Notice of' Premiurn Options; for Standard Premiums of' L.iess than $251F101010 <br /> (Ganllt) <br /> F:1411e,asil, lindilicate b6l'IMM the I1RU-SIM111LIFIVI 9:101#1111C)irii 1(c,:iiiu wlshtir) siellact Ifolu ima,y chim::ose iiu:mly onle, r.:Pptloin ainildi you <br /> C911111311110t,chartge optliiu:ioins diuorhrtqthiiF.0 RgIrGPIFTIGIVIt 138,111110d <br /> INREMIUM <br /> ............. <br /> 1. 1,.-] Ftegiular P'llernh,111M (;)p.tllolinh 19,9152 <br /> 2. IEl Deductible IPiremilum Option <br /> [)eductilble options sire sysiillabl iirn ireturn for a Ipremmirn credit applied to your estimated standard <br /> Rrernlum of$21,521. -l'he deductible will apply per occurrence to paid medical costs only.. <br /> There its no aggregate limit.. <br /> 139duckibl IPremilurn Cil'adit Not 11:)gllposft <br /> �2191111`OCCIL111ineiruice Qred�lt Airrwiuir1 F111ireirnhiiii,n <br /> ........................................................................... <br /> $250 1.00% ...215 19,737 <br /> $500 1.70% 366 19,586 <br /> $18000 2.90% -624 19,328 <br /> $2,500 5.00% -1,076 18,876 <br /> $5,000 7.50% 1,614 18,338 <br /> $10,000 10-50% -2,260 17,692 <br /> $25,000 17.00% , 659 16,293 <br /> 13 $50,000 22.50% 4,842 15,110 <br /> This quotation is for a deposit premium based on your estimate of payroll and selected options. Your final actual <br /> premium will be computed after an audit of payroll subsequent to the close of your agreement year and will be <br /> subject to revisions in rates, payrolls and experience modification. While you are a member of the LMCIT Workers' <br /> Compensation Plan, you will be eligible to participate in divident distributions from the Trust based upon claims <br /> experience and earnings of the Trust. <br /> If you desire the coverage offered above, please return this signed document for the option you have selected. <br /> This quotation should be signed by an authorized reprosentative of the city requesting coverage., <br /> ............... ........................................................................................................................................................................................................................ <br /> Sgi�iatii . <br /> uiie I Itle i�)Iate <br /> Pawn 2 of 3 II.,IIM4514(3102)()Rev..1116) <br />