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� r�. . . ��w��r v��r� -•'�." "...... vVV�M <br />if "yes", complete the following: <br />s�ma <br />�oaeon <br />� �..� u�.� <br />k�swena C�rlsr PoRcy Numbar <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 />IV. PREMIUNCALCULATION <br />(Coverage wlil not be provided if thls section Is not completed) <br />1. pletelydescribebusines�s� .operations_ <br />� <br />2�%Do you lease employees to or from another company? <br />❑ Yes, ((we) lease employees to other companies* . E�py� lea&g companies &temporary agencies <br />Q,Yes, I(we) lease employees from other companies must be registered with the Department of Commerce or <br />provide an exemption certificate. For more information <br />��•�� caN the Department of Commerce at 612/287-7035. <br />If not, are you a temporary help agency? � Y e s �lo <br />3 <br />es <br />amployees �classification <br />� <br />**Calculations of Estimated Annual Premium <br />Subject to Insurance Company Audit <br />Clerical Office <br />Outside Sal�spe rson- No Product Delivery' <br />Drivers Chauffeurs Helper6 <br />Total Estimated Minimum Deposit <br />Annual Premium ir <br />under�2,000 100% <br />$2,000— $10,000 50% <br />over $10,000 259�0 <br />Code <br />�Ia <br />ss� o <br />8742 <br />7380 <br />TOTAL REMUNERATION BASIS <br />Employees <br />� � � 8�� <br />te I Premium <br />'ayment 7ot:al Premium�l�f ' <br />• ... <br />Experience Modiiication � <br />MCPAP Credit Factor <br />3 quarterly Standard Premium <br />9 monthly <br />Pius Expense Constant <br />Total Estimated Annual P�emium ` <br />Deposit Premium Percentage U� <br />Deposit Premium <br />�Are the a�roll amounts listed above I erthan those appearing on your most recent poliay or audit? � � <br />� �Yes �0 No <br />It"yes , eas+eprov mentadionverifying the payroll amounts listed above. The MWCIA will verify the payroll <br />amounts by dass. Covera�e may be refused if adequate documentation is not provided. <br />� is premium being financ�dthrough a.premiumfinancecompany? ❑Yes �JNo <br />if "yes", please provide a copy of the premium finance agreement. <br />�Do you USe independent contract& . ❑Yes �No <br />�f "yes", you must maintain documenta�onw c supportst att eyare.infact.independentcontractbrs. if such docu- <br />mentation is not available, or if the servic'tng cantractarforthe Ass�gned Risk Plan finds evidence of an employment <br />relationship, then premium may be char�ed as if the individuals were employees. <br />"Subiect to change according to rules governing the Yinnesots Workers' Compensation Assigned Risk Plan. <br />�Cas !FA Atl hsw4 w�ws in� srwl�n�iww wt w���.�..� ww�iw.... <br />