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<br />07/06/2004 03:88 <br /> <br />6514848572 <br /> <br />ALL COUNTY AGENCY <br /> <br />PAGE 03/84 <br /> <br />4. Do you (applicant) have ~ Workers' Compensation Insurance polley in foroe? <br />If "yes". Indicate expiration or cancellation date: <br />, cancelled or non-renewed, who initialed cancellation: DEmployer o Insurance Company <br />5. Are there operations in states other than Minnesota? DVes ~o <br />If "yes", complete the following: <br />,.... <br /> <br />o Yes ~o <br /> <br />"""""" <br /> <br />. lMUltlt\ce c:am.r <br /> <br />~Ill:VNUd\bAr <br /> <br />Note: The Minnesota Assigned Risk Plan does oct provide coverage for permanent out of stale operations. Temporary out <br />of slale operations are covered only as provided by MInnesota Statute. <br /> <br />rv. PFlI:MIUM CAI..CULATlON <br />(Coverage will not be provIded if this section is not completed) <br /> <br />1. Completely describe business and operations: <br /> <br />(ThiS qu"stion must be answered) <br /> <br />~ ~ ~g ':)~ ~~ tv /1f... C;:~c..e./l-/ C:~ r::.:;",.,{. <br /> <br />2. Do you lease employees to or from another company? <br />o Ves, r (we) lease employees to other companies' <br />o Ves, I (we) lease employees from other companies <br />~No <br /> <br />If not, ~re you a temporary help agency? <br /> <br />(This question must be answered) <br /> <br />. Employee leasing CQMpanles & temporary ego",,"," <br />mutt be registered with ihe OepartmeO'\t ot COmme"", or <br />pmvIdo en I!l<llmplion oel1ffl""t.. fur more Information <br />QalI11le Oepartment ot Commerce at 5511297-7035 <br /> <br />Dves ~o <br />3. -Calculations of EstImated Annual Premium Subject to Insurance Company Audit <br /> <br />. <br /> <br />!:Ie by loe:trtl~n 1M dUll.. of EmpIoyeta ar a...IdClltlGn ~ COd. ~aIl;~ -.......-... - ........... <br />'5Mi:JJJol- ~ ~MJ("- ,rev&.> ;l... !).t) 000 .;l.t;;:, (S(-(. <br /> "" R.~ '{.. <br />c_"""" ..,. <br />~~llrl.H(I.~=D~ 07'" <br />Crtwrs;~r&'H/t"'.r.:t ""'. <br /> ...... <br />Terrorism Risk Insurance Act TObIIPnarnlum <br />trOD Ircqaa., Llrtllb <br />~OOCl + TOOX ~~ ~rilJl'ICIIJolIQQll\t:8l1Qn <br />'l'obIIRernlln~t1"", .... lni&OrtOnr.rro.um~!H Una Sfand8t'd Ptemhnn <br /> MCI'AI' <br /> MMrRa1lnq <br />Total Estimated Minimum D"JOSit ~1'l5.von&twlt $150 <br />Payment <,t <br />Annuar Premium Re<lufr~ 8R~is'- _C_ <br />under $2,000 100% lbflll ~4nn.Ial PnirnUn I?f.. <br />$2.000 - $10,000 50% 3 quarterly MN SpDdal Comp. F<,II\d APH!m6N (Swart PNmlum J. A-:!m) 4.5% .'5 :;; <br />over $10,000 26% 9 monthly PtJkf 1bmI .e..,/7l8htd Ccm 7'71 <br /> DI!pO$t P\"eIWUm Pe~ , <br /> Depoetl Pl'l!llf'1lum ~ 7703 <br /> <br />4. Are. th~roll amounts Iist~bove lowe~an those appearing On your most recent policy or audit? <br />.'.dq' 'h""~t~H~r,'1~ 0 Yes No <br />It "yes," please provide documentation verifyin the payroll amounts listed above. The MWCIA will verify the pay- <br />roll amounts by class. Coverage may be refused if adequate documenlation is nolproVidecL <br /> <br />:.l.Premium being financed through a premium finance company? DVes Wf"No <br />.yes", please provide a copy of the premium finance agreement. ""'\ <br /> <br />6. Do you use independent contractors? DVes aNa <br />If "yes," you must maintain documentation which supports that they are, in fact, incl~dent contractors. If such docu- <br />mentation is not available, or if the servicing contractor for the Assigned Risk Plan finds evidence of an employment <br />relationship, then premium may be charged as if the individuals were employees. <br />~ubJect to Change KeOfdlng to rulaa govomtt1g tho Minnesota. Workers' Compensadon AsslgnltCt R)~ Plan~ <br />-"$.. #4 on baCk pago for explanation a' Dayment options. <br /> <br />2 <br />