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8d? (L; 1VlA~-5 VIII. STATEMENT OF AGENT OF RECORD do hereby certify that I am a licensed insurance agent of the State of Minnesota. ~ ~~ ~O~ ') ~--S-+~) 3>- ~-d.d.fY ZIP Code Telephone Number or Social Seourity Number Are you charging a service fee on this policy? 'pfVBS D No If so, the fee must be mutually agreed to in writing by both the agent and the insured. A separate agreement must be prepared for each poli year that a fee is charged. (This question must be answered) tD {t ;()-;r- Note: I MINNESOTA WORKERS' COMPENSATION ASSIGNED RISK PLAN RULES AND PROCEDURES PLEASE READ CAREFULLY 1. Applications will not be accepted by FAX machine, except for quoting purposes. 2. Only Minnesota statutory workers' compensation coverage and employers' liability coverage will be provided. USL & H coverage is available. Other States and Voluntary Compensation Coverages are not available. 3. Payrolls and classifications included in the Premium Calculation Section of the application are subjectto review by Association staff. Payrolls should be indicated for each classification. If the proper classifications cannot be determined, Association staff will classify the employer on the basis of the description of operations as stated on the application, and prepare a premium quotation forthe applicant or agent. Final premium will be determined by premium audit upon expiration ofthe policy. 4. Policies under $2,000 annual premium require 100% deposit premium. For policies of $2,000 - $10,000 the employer shall have the option of paying 50% or 100% of that amount as the deposit premium. For policies of $10,000 or more, the employer shall have the option of paying 25%, 50% or 100% as the deposit premium. If 50% of premium is paid, the remainder shall be paid in three equal quarterly installments. If 25% is paid, the remainder shall be paid in nine equal monthly installments. 5. The servicing contractor may issue the policy on an interim reporting basis, which requires the insured to submit monthly or quarterly payroll report forms. Requests to have the policy issued on an interim reporting basis will be honored in accordance with the guidelines established. 6. Agents are not agents of the Assigned Risk Plan and cannot issue certificates of insurance or bind coverage. 7. Commissions on Minnesota Workers' Compensation Assigned Risk Plan policies are as follows: Policy Premium Commission under$1,OOO 5% $1,000 to $5,000 4%, but not less than $50 $5,000 to $1 0,000 3.5%, but not less than $200 over $10,000 1 %, but not less than $350 Commission maximum of $3,500 per policy if no service fee is charged. Commission maximum of $1,500 per policy if a service fee is charged. Commissions are subject to change without notice. 8. In the event the policy is terminated or a change is made which results in a return premium to the insured, the agent will be required to return the unearned commission portion of such return premIum. 9. If you have questions aboutthe rules governing the Assigned Risk Plan, orwould like additional information, please contact the Minnesota Workers' Compensation Insurers Association at (612) 897-1737.