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<br />\2:/ 1"\1 1:1 U 11:11 1:1 uperauons In states orner man Mlnnesota'( <br />If "yes n, complete the following: <br /> <br />UY6S UNO <br /> <br />Stale <br /> <br />Location <br /> <br />Insurance Carrklr <br /> <br />Policy Number <br /> <br />Note: The Minnesota Assigned Risk Plan does not provide coverage for permanent out of state operations. Temporary out of <br />state operations are covered only as provided by Minnesota Statute. <br /> <br />(j)C <br /> <br />IV. PREMIUM CALCULATION <br />(Coverage will not be provided If this section is not completed) <br /> <br />pletely describe business and,opE:lrations:_ <br />r <br /> <br /> <br />(This question must be answered) <br /> <br />(This question must be answered) <br /> <br />~o you lease employees to or from another company? <br />o Yes, I (we) lease employees to other companies* <br />~~s, I (we) lease employees from other companies <br /> <br /> <br />If not, are you a temporary help agency? 0 Yes Wo <br /> <br />"Calculations of Estimated Annual Premium <br />Subject to Insurance Company Audit <br /> <br />... Employee leasing companies & temporary agencies <br />must be registered with the Department of Commerce or <br />provide an exemption certificate. For more information <br />call the Department of Commerce at 612/297-7035. <br /> <br />TOTAL REMUNERATION BASIS <br />otal Remuneration Rate Premium <br /> <br />Total Premium <br /> <br />Experience Modification <br /> <br />MCPAP Credit Factor <br /> <br />Standard Premium <br /> <br />Plus Expense Constant <br /> <br />Total Estimated Annual Premium <br /> <br />Deposit Premium Percentage <br /> <br />Deposit Premium <br /> <br />~ Are the a roll amounts listed above ICLwer than those appearing on your most recent policy or audit? "\' <br />· -. . - . . .. H3-Yes '0 No . <br />"yes", pease provl e ocumentation verifying the payroll amounts listed above. The MWCIA will verify the payroll <br />amounts by class. Coverage may be refused if adequate documentation is not provided. <br /> <br />~ Is premium being financed through a premium finance company? 0 Yes ~o <br />If "yes", please provide a copy of the premium finance agreement. <br /> <br />@DOYOU use independent contractorS~liIlJS'~H'IIII1PI."1'-~*IIJ:lliTI::mliJJ 0 Yes ~o <br />If "yes", you must maintain documentation w IC supports t at they are, in fact, independent 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 /> <br />3. <br /> <br />~Describe by location the duties of <br />':r~Classification <br /> <br /> <br />.1;j{ <br /> <br />Class <br />Code <br />~17.l <br /> <br />t) <br /> <br />Clerical Office <br />Outside Salesperson - No Product Delivery. <br />Drivers Chauffeurs Helpers <br /> <br />Total Estimated Minimum Deposit <br />Annual Premium Required <br /> <br />under$2,000 100% <br />$2,000 - $10,000 50% <br />over$10,OOO 25% <br /> <br />8810 <br />8742 <br />7380 <br />Payment <br />Basis *** <br /> <br />3 quarterly <br />9 monthly <br /> <br />**Subject to change according to rules governing the Minnesota Workers' Compensation Assigned Risk Plan. <br />.**~ JliJ. nn hl'.:l.f'''' ru."'.cr. fl'\P AVl'\.lal'llofi"p\ _f ...e.u_a..... ......_.1___ <br /> <br />I <br /> <br />