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`�� K- , VIII. STATEMENT OF AGENT OF RECORD � ,"U�-s doherebycertifythatlamalicensedinsuranceagentof heState of Minnesota., (PriM a Ypa M Name of 1�0eM) Q ' c:, a,�� s . Qc.-.� -��c v��C3_ 'J Name a ApMCy �t -. e & & - - h��. 5-�_� Federal Employers I.D. Number y� - �� 3� I�l� or SocialSeourity Number Are you charging a service fee on this policy? �Y�S ❑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 foreach pol� yearthata fee is charged. X � / �— �� -O Note:l n'fe�`identaQent�o ustattachacoqy of,vour Minnesota non-resident license or vou will not be recognized as agent record and no com ssion will be paid. MINNESOTA ORKER$'COMPENSATIONASSIi�NEDRISKPLAN RULES AND PROCEDURES PLEASE READCAREFULLY 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 aresubject to 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 descri�tion ofoperations as stated on the application, and prepare a premium quotation for the applicant or agent. F�na �remium will be determined by premium audit upon expiration of the policy. 4. Policies under $2,000 annual premium require 100% de:po sit premium. For policies of $2,000 —$10,000 the employer shall have the option of paying 50% or 100% o f th�at amount as the d�posit premium., For policies of $10,000 or more,.the employer shall have the option of paying 25%, 50% or 10b% 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: PolicyP re mi u m under $1,000 $1,000 to $5,000 $5,000 to $10,000 over $10,000 � 0 Commission 5% 4°to,butnotlessthan $50 3.5%,butnotlessthan$200 1°to, 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 oraChange 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. Ifyou have qu�estions about the rules governing the Assigned Risk Plan, orwould like additional information, Please contact th�Minnesota Workers' Compensation Insurers Association at (612) 897-I 737.