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HomeMy WebLinkAboutInsurance 2006/2007 Applications & Policy League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 Phone (651)215-4173 Notice of Premium Options for Standard Premiums of $25,000-$50,000 OAK PARK HEIGHTS, CITY OF Agreement No. : 0200 0 72921 PO BOX 2007 Agreement Period: From: 7/07/2007 OAK PARK HEIGHTS MN 55082 To: 7/07/2008 Enclosed is a quotation for workers' compensation deposit premium. ESTIMATED DEPOSIT PAYROLL DESCRIPTION CODE RATE PAYROLL PREMIUM SEE ATTACHED SCHEDULE FOR DETAILS 1 !3 s.' a .® JUN - 8 2001 E � b - — Manual Premium 41405. Experience Modification .91 Standard Premium 37679. Deductible Credit 0% Premium Discount 3105. Net Deposit Premium 34574. MANAGED CARE CREDIT Cities that enroll with a state-certified managed care organization(MCO) receive a 2% premium credit on their work comp coverage. Standard Managed Care Net Deposit Premium Credit Premium 37679. 2% 33820. OPTIONS Please indicate below the premium option you wish to select. You may choose only one option and cannot change options during the agreement period. NET DEPOSIT PREMIUM 1. - Regular Premium Option 34574. or, with 2% Managed Care Credit: 33820. LM 4514(3/02) League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St, Paul, MN 55103-2044 (651)215-4173 The "City" Agreement No. : 0200072921 Agreement Period From: 7/07/2007 OAK PARK HEIGHTS, CITY OF To: 7/07/2008 PO BOX 2007 OAK PARK HEIGHTS MN 55082 CONTINUATION SCHEDULE FOR QUOTATION PAGE REMUNERATION RATE CODE DESCRIPTION EST. PREM 32528./ 7.80 5506 STREET CONSTRUCTION 2537. 120871. ' 3.64 7520 WATERWORKS 4400. 73524.-' 2.48 7580 SEWAGE DISPOSAL PLANT 1823. 719553.' 3.90 7720 POLICE 28063. 381304. ' .72 8810 CLERICAL OFFICE EMPLOYEES NOC 2745. 5101. -' 3.05 9016 SKATING RINK OPERATION 156. 39944.E 3.31 9102 PARKS 1322. 73050.-' .42 9410 MUNICIPAL EMPLOYEES 307. 28750. / .18 9411 ELECTED OR APPOINTED OFFICIALS 52. Manual Premium 41405. Rti _ 3s I i y 4/0-12 /, Fri 3 v/ Yo s /40./ _ ��<< 3� 014, /to 04, /, & `l 276 '21 G7y \ (1)...4,4 - 9 3-28' 3 /, 5 3 y, `7 It 10 /-416Z.94)-510 (i '705-`/8900-(0 4. 706 -11 oD--.204, Agent: 411709883 00874: FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS 232 S LAKE ST FOREST LAKE MN 55025- 6/06/2007 LM 4680(8/99) 2. _ Deductible Premium Option Deductible options are available in return for a premium credit applied to your estimated standard premium of $ 37679. The deductible will apply per occurrence to paid medical costs only. There is no aggregate limit. Deductible Premium Credit NET DEPOSIT PREMIUM per Occurrence Credit Amount with MCO Credit without $250 2.00% 754. 33066. 33820. $500 4.00% 1507. 32313. 33067. $1,000 5.50% 2072. 31748. 32502. $2,500 9.00% 3391. 30429. 31183. $5,000 13.00% 4898. 28922. 29676. $10,000 18.50% 6971. 26849. 27603. 3. _ Retrospective Rates Premium Option Retro-Rated Est.Minimum Retro-Rated Est.Maximum Minimum Factor Premium Maximum Factor Premium .703% 26488. 1.150% 43331. .669% 25207. 1.250% 47099. .607% 22871. 1.500% 56519. This quotation is for a deposit premium based on your estimate of payroll and selected options. Your final actual premium will be computed after an audit of payroll subsequent to the close of your agreement year and will be subject to revisions in rates, payrolls and experience modification. While you are a member of the LMCIT workers' Compensation Plan, you will be eligible to participate in dividend distributions from the Trust based upon claims experience and earnings of the Trust. If you desire the coverage offered above, please return this signed document for the option you have selected. This quotation should be signed by an authorized representative of the city requesting coverage. Signature Title Date LM 4513(3/02) • • • d • ff T ww City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal To: League of MN Cities his.Trust Fax: 651-281-1298 From: Gary Brunckhorst Date: 5/31/07 Re: Renewal Data Pages: 4 CC: ❑ Urgent ❑For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle Notes: • Y • • League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 APPLICATION FOR: L- N,•.( o 4- CG6.k Pe.f k !V a,St,v)I-S County: i-v.■ Mailing Address: P 0 • (c; ,c ao o 3 Phone: 1051- 431- 4''-13'1 City, State, Zip: Oc‘IL Pc% IC 14o it?1. S Vv1vt SSG 82 Contact Person: Gam -•1 0)r vk'Nt. 110tiv>>, Title: S r- Ac-4uv ^"" ^' 2000 Census Population:Po 1 p Current Estimated Population: I-W l0 y Total Expenditures All Operations: Is the applicant a Member of The League of Minnesota Cities? nYes nNo Agency: Le"." sktr k vA 5 4:-)c? L v Address: a - 5o Lot k t S City, State, Zip: core 7 i Let 11.4 v1 5 5 0 620 S Telephone: ((D t) ►4 p4 -3333 Facsimile: ((QS 1 ) 41o4 7S61V Agency Contact: K."}2 S • p 45. Email Address: Date of Council Resolution or Contract Appointing the Agency: I.),-2Ss-v.•P AGENT COMPENSATION: rxi 2% n City Will Compensate the Agent Directly nOther Please specify: Please complete and return with Renewal Data Information. Any questions please call 651-215-4173. League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 RENEWAL DATA The "City:" OAK PARK HEIGHTS, CITY OF Agreement No. : 0200072920 PO BOX 2007 Quote To: OAK PARK HEIGHTS MN 55082 Quote Due On: 6/01/07 Agreement Expires: 7/07/07 Your coverage under the LMCIT Self-Insured Workers'Compensation program will expire soon.This Renewal Data sheet will be used to generate a premium quote for the different workers'compensation plans available.A copy of the City's previous year's selected coverages and premiums is attached for your reference. Coverage Options All of the options available to the City are outlined below,and described in the accompanying memo, Things to Think About When Renewing Your City's Workers' Compensation Coverage. You can select any coverage options in which the City may be interested. Premium quotes for all coverage options will be provided,and a final coverage decision can be made at the time you receive the complete quote. Elected Officials: Please indicate if the City would be interested in covering elected officials.Yes X No If yes,please list the estimated annual payroll for all elected officials the City would like to cover under workers'compensation. The 2007 premium rate for mayors and council members is$ .18 per$100 of payroll.This rate is applied to the greater of either the official's actual salary or an imputed salary of$70 per week. Note: Coverage for elected officials requires a resolution passed by the City Council. Payroll Description Code Amount Elected Officials 9411 $ 15 O Members of Separate Administrative Boards: Please indicate if the City would be interested in covering members of separate administrative boards.Yes No X If yes,please select any separate administrative boards the City would like to cover under workers'compensation.(This coverage includes Board Members only.) 1. Utility or utility commission 5. Welfare or public relief agency 2. Port authority 6. School board 3. Housing and redevelopment authority 7. Joint powers board 4. Hospital or nursing home board or commission 8. Other Employees of Separate Administrative Boards: If the City has elected to cover specific Board Members above,the City can also choose to cover employees of those boards. Please indicate which type of quote the City would like: No quote for administrative board employees. Combined quote to include employees of both the administrative board and the City. Separate quote for employees of the City and each administrative board selected above. Volunteers: Please indicate if the City would like to cover City volunteers not designated as employees,such as coaches,instructors,event workers, "clean-up"day volunteers,etc.(Volunteer firefighters,ambulance attendants,first reponders, law enforcement assistance volunteers,civil defense volunteers,and any other volunteers defined by statute as employees for purposes of work comp coverage are already covered and are not part of this election.) Yes No X (over) City Employees: Please indicate the estimated payroll for City employees for the coming policy year.The payroll descriptions and codes provided are the most commonly used.If you need to add additional payroll descriptions,please use the blank spaces and the codes on the attached list. Sick,holiday,and vacation pay should be included in the payroll totals.Do not reduce payrolls for sick,holiday,and vacation pay. Does your City have a flexible benefits plan such as a cafeteria plan,Section 125 plan,or flexible reimbursement account plan? Yes X No Employee contributions to a flexible benefits plan should be included in the payroll figures you provide. City contributions should not be included.(This is similar to how these plans are treated under PERA.) Payroll Description Code Amount Payroll Description Code Amount Ambulance Services (Not Volunteer) 7380$ Sewage Plan 7580$ 13 ca a' Ambulance Services (Volunteer)7381$ Off Sale Liquor Store 8017$ Building Operations 9015$ Street and Road Construction5506$ 3a 5 l S City Shop and Yard 8227$ Waterworks 7520$ 0,0 `d 1t Clerical Office 8810$ Other: R0nk Aa-te4,3.1.44-5 $ Sio Electric and Steam Power 7539$ Other: $ Firefighters (Not Volunteer) 7706$ Other: $ Firefighters (Volunteer) 7708pop Other: Municipal Employees 9410$ 13 0 5o Other: $ Parks 9102$ 39 11-14 Other: $ Police 7720$ 1 'tC► 553 Other: $ ' Restaurant and Bars (on sale) 9084$ Other: $ PREMIUM OPTIONS Please select the premium options below in which the City is most interested.All of the premium options selected will be quoted to the City;however,only one premium option can be ultimately assigned for the coming plan year. Regular Premium Option: Please indicate if the City would be interested in the regular premium option.Yes X No Deductible Options: Please Indicate the deductible level and associated premium discount the City would like to consider. Deductible Premium Credit $250 2.00% $500 4.00% $1,000 5.50% $2,500 9.00% $5,000 13.00% $10,000 18.50% Retrospective Rating: Please indicate if the City would be interested in retrospective rating(if applicable).Yes No X Managed Care Option: Please indicate if the City participates in a state-certified managed care organization(MCO)for workers' compensation benefits,and if so,the name of that organization.Yes No X MCO: Contact Information: Please provide us with a contact for questions about the City's workers'compensation coverage. City Contact Person '3.-' y N v"5} Phone (o 61-141q- 4431 Email irons i@ pm/ Please fax this completed form to the League of Minnesota Cities Insurance Trust at 651-281-1298. If you have any questions,please contact Barb Meyer,Policy Services Technician,by phone at 651-215-4173 or 800-925-1122,or via email at bmeyer2clmnc.org. • • 1 k ...2-4, 4,- hts City of Oak Park Heig 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal To: LMC Ins. Trust Fax: 281-1298 From: Gary Brunckhorst Date: 6/5/07 Re: Renewal Pages: 4 CC: ❑ Urgent ❑For Review ❑ Please Comment ❑ Please Reply 0 Please Recycle Notes: League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 APPLICATION FOR: 4 0o∎ Pte✓ k k4�; cj \4 County: t1I ra.�j1.N;h t, 1-e A Mailing Address: p.0 • (j ,c a o O Phone: US I- Lk-5cl- 4"a 301 City, State, Zip: 00.1L. NA,"1t. 14 a, �'S Met✓1 SS°5 a Contact Person: Gi.r 0),ti L 14,t'w i Title: S r- Ac-c-u""''a^' 2000 Census Population: 1)k -1 Current Estimated Population: y'. l 1-k Total Expenditures All Operations: Is the applicant a Member of The League of Minnesota Cities? nYes ❑No Agency: L&%' y-. V.. .t ,1 c (.y Address: 5o, k t 5 4 City, State, Zip: cc re 5 a Lci.tit h 5 50 2 5 2 (PG S Telephone: (tDSi) ykp 4 -3'S33 Facsimile: (t95t ) L1`e'4 -'15°t V Agency Contact: Iko.•■} e ; p n .15 Email Address: Date of -� ate o Council Resolution or Contract Appointing the Agency: i a-2ts AGENT COMPENSATION: 1111 2% n City Will Compensate the Agent Directly nOther Please specify: Please complete and return with Renewal Data Information. Any questions please call 651-215-4173. League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 RENEWAL DATA The "City:" OAK PARK HEIGHTS, CITY OF Agreement No. : 0200072920 PO BOX 2007 Quote To: OAK PARK HEIGHTS MN 55082 Quote Due On: 6/01/07 Agreement Expires: 7/07/07 Your coverage under the LMCIT Self-Insured Workers'Compensation program will expire soon.This Renewal Data sheet will be used to generate a premium quote for the different workers'compensation plans available.A copy of the City's previous year's selected coverages and premiums is attached for your reference. Coverage Options All of the options available to the City are outlined below,and described in the accompanying memo, Things to Think About When Renewing Your City's Workers' Compensation Coverage. You can select any coverage options in which the City may be interested. Premium quotes for all coverage options will be provided,and a final coverage decision can be made at the time you receive the complete quote. Elected Officials: Please indicate if the City would be interested in covering elected officials.Yes X' No If yes,please list the estimated annual payroll for all elected officials the City would like to cover under workers'compensation. The 2007 premium rate for mayors and council members is$ .18 per$100 of payroll.This rate is applied to the greater of either the official's actual salary or an imputed salary of$70 per week. Note: Coverage for elected officials requires a resolution passed by the City Council. Payroll Description Code Amount Elected Officials 9411 $ A i3 15 0 Members of Separate Administrative Boards: Please indicate if the City would be interested in covering members of separate administrative boards.Yes No XC If yes,please select any separate administrative boards the City would like to cover under workers'compensation.(This coverage includes Board Members only.) 1. Utility or utility commission 5. Welfare or public relief agency 2. Port authority 6. School board 3. Housing and redevelopment authority 7. Joint powers board 4. Hospital or nursing home board or commission 8. Other Employees of Separate Administrative Boards: If the City has elected to cover specific Board Members above,the City can also choose to cover employees of those boards. Please indicate which type of quote the City would like: No quote for administrative board employees. Combined quote to include employees of both the administrative board and the City. y Separate quote for employees of the City and each administrative board selected above. Volunteers: Please indicate if the City would like to cover City volunteers not designated as employees,such as coaches,instructors,event workers, "clean-up"day volunteers,etc.(Volunteer firefighters,ambulance attendants,first reponders, law enforcement assistance volunteers,civil defense volunteers,and any other volunteers defined by statute as employees for purposes of work comp coverage are already covered and are not part of this election.) Yes No X (over) City Employees: Please indicate the estimated payroll for City employees for the coming policy year.The payroll descriptions and codes provided are the most commonly used.If you need to add additional payroll descriptions,please use the blank spaces and the codes on the attached list. Sick,holiday,and vacation pay should be included in the payroll totals.Do not reduce payrolls for sick,holiday,and vacation pay. Does your City have a flexible benefits plan such as a cafeteria plan,Section 125 plan,or flexible reimbursement account plan? Yes X No Employee contributions to a flexible benefits plan should be included in the payroll figures you provide. City contributions should not be included.(This is similar to how these plans are treated under PERA.) Payroll Description Code Amount Payroll Description Code Amount Ambulance Services (Not Volunteer) 7380$ Sewage Plan 7580$ 1'5 5•14 Ambulance Services (Volunteer)7381$ Off Sale Liquor Store 8017$ Building Operations 9015$ Street and Road Construction5506$ 3a 5 a S3 City Shop and Yard 8227$ Waterworks 7520$ 1 ao rd, 1 Clerical Office 8810$ 3`31304 Other: R ,.i c Att anti",44S $ Sic) k Electric and Steam Power 7539$ Other: $ Firefighters (Not Volunteer) 7706$ Other: $ Firefighters (Volunteer) 7708pop Other: $ Municipal Employees 9410$ 1',o',o Other: $ Parks 9102$ W y y Other: $ Police 7720$ `"l tc1 55 :3 Other: $ Restaurant and Bars (on sale) 9084$ Other: $ PREMIUM OPTIONS Please select the premium options below in which the City is most interested.All of the premium options selected will be quoted to the City;however,only one premium option can be ultimately assigned for the coming plan year. Regular Premium Option: Please indicate if the City would be interested in the regular premium option.Yes X No Deductible Options: Please Indicate the deductible level and associated premium discount the City would like to consider. Deductible Premium Credit $250 2.00% $500 4.00% $1,000 5.50% $2,500 9.00% $5,000 13.00% $10,000 18.50% Retrospective Rating: Please indicate if the City would be interested in retrospective rating(if applicable).Yes No X Managed Care Option: Please indicate if the City participates in a state-certified managed care organization(MCO)for workers' compensation benefits,and if so,the name of that organization.Yes No X MCO: Contact Information: Please provide us with a contact for questions about the City's workers'compensation coverage. City Contact Person 3" y '\v 1 b+ Phone (0 61-431- 44 Y1 Email J`no46 Y .c:i.y tit ua if.pay►�. het h'S•c.r,'^1 Please fax this completed form to the League of Minnesota Cities Insurance Trust at 651-281-1298. If you have any questions,please contact Barb Meyer,Policy Services Technician,by phone at 651-215-4173 or 800-925-1122,or via email at bmeyer2®lmnc.org. League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 Phone (651)215-4173 Information Page 1. The"City" RENEWAL Agreement No.: 0200072920 OAK PARK HEIGHTS, CITY OF PO BOX 2007 1.,--y1,7,1 j 3 A: r R j� ,..,. "City" is: x City OAK PARK HEIGHTS MN 55082 LA RING Irir(),i�'�1=` ° — Joint Powers Entity DO NOT PAY Y Other (describe) 2. The Agreement Period is from 12:01 a.m. 7/07/2006 to 12.01 a.m. 7/07/2007 at the "City's" address. 3. A. Workers' Compensation Coverage: Part One of the Agreement applies to the Workers' Compensation Law of any state of the United States of America and the District of Columbia. B. Employers Liability Coverage: Part Two of the Agreement applies to work in each state listed in item IA. The limits of our liability under Part Two are: Bodily Injury-Each Occurrence $1,000,000 Bodily Injury by Disease-Agreement Limit $1,000,000 C. Part Three of the Agreement applies to Infectious Disease Diagnostic Testing. D. Part Four of the Agreement applies to Peace Officers' Posttraumatic Stress Syndrome Benefit. E. This Agreement includes these amendments and schedules: 4. Retro-rating option selected? Yes x No 5. Elected Officials Covered? Yes Boards and Commissions Covered (List) NONE 6. The premium for this Agreement will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rates Entries in this item,except as specifically provided Estimated Estimated Total Per$100 of Code elsewhere in this Agreement; Do not modify any of the Annual Annual Remuneration No. other provisions of the Agreement Premium Remuneration SEE ATTACHED SCHEDULE FOR DETAILS Manual Premium 41275. Experience Modification .78 9080. Standard Premium 32195. Managed Care Credit 0% Deductible Credit .0 % Agent: 411709883 592.22 Premium Discount 2584. 00874 FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS Net Deposit Premium 29611. 232 S LAKE ST FOREST LAKE MN 55025- 8/02/2006 LM 4670(12/99) League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 (651)215-4173 The"City" Agreement No.: 0200072920 OAK PARK HEIGHTS, CITY OF r'� r= 4i�w� 1,�, , P fi '' Agreement Period From: 7/07/2006 LAI 41 i t\r 1, , 3 .': To 7/07/2007 FO BOX 2007 �, NO-> ; ;�' OAK PARK HEIGHTS MN 55082 O i HAY CONTINUATION SCHEDULE FOR INFORMATION PAGE REMUNERATION RATE CODE DESCRIPTION EST. PREM 19828. 7.05 5506 STREET CONSTRUCTION 1398. 123926. 3.04 7520 WATERWORKS 3767. 74356. 4.03 7580 SEWAGE DISPOSAL PLANT 2997. 715608. 4.05 7720 POLICE 28982. 378922. .60 8810 CLERICAL OFFICE EMPLOYEES NOC 2274. 4820. 2.54 9016 SKATING RINK OPERATION 122. 22169. 3.21 9102 PARKS 712. 83307. 1.10 9410 MUNICIPAL EMPLOYEES 916. 26000. .41 9411 ELECTED OR APPOINTED OFFICIALS 107. Manual Premium 41275. Agent: 411709883 00874 : FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS 232 S LAKE ST FOREST LAKE MN 55025- 8/02/2006 LM 4680(8/99) t , • League of°Minn`esota Cities: Insurance imst 145 University Avenue West,"St. Paul, MN 55103 2044 (651)281-1200 • (800)925 1122 liagwa of Minnesota Caw, Fax: (651)2$1-1298 • TDD: (651)281 1290 u.,.pnegiotJ g amaenancq - .. W�WW;1rn rC org. - - ' MINNESOTA WORKERS' COMPENSATION NOTICE OF RENEWAL This information is provided to assist you in understanding your workers' compensation coverage and renewal options. Pl ease read all the:information carefully before:making selections for the net ;overage period. The following information is included: • Renewal Data form • Copy of previous year's coverage selection and premium information page • Risk management memorandum: Things to Think About When Renewing Your City's Workers' Compensation Coverage If you have additional questions about-the coverage options:available to your City,:.please cent i®t the League of Minnesota Cities Insurance Trust: Barb Meyer,.Policy Services Technician Mike `'Wozniak, Underwriting;Manager Phone:.651-215.-4173 Phone: 651-215-4090 Fa,K: 651-281-1298 Fax: 651-281-1298 Email: bmeyer2 @linnc.org "Email: niwozniakradninc.nrg Deb Anger; Account Manager -- Ann Gergen, Associate AdmTmistratdrx - Phone: 651-215 4170 Phone: 651-281-1291 '' -' t Fax: 651-281-1297 Fax: 651-281-1298 . - - Email: danger @lmnc.org Email:"agereen4?1nlne.or'g ' Any of the above listed individuals,can also be reached at 800=925211'2. `., ; ? ` , . 1 a „ _:_,.. h 1 . - 1 p.. i ...,'t� )i-• ;,--,-;',:-.i., , , ., r- ,.,....:-.,.., : -._ }? -• ,cam ' ,_ . ,,, ,,, ..,-„..,,-,,,. . , ,..,,,, r,._ AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION'EMPLOYER '' , er 't'N '- Viil LMCIT LMRisk Management Information League of Minnesota Cities 145 University Avenue West,St.Paul,MN 55103-2044 Cities promoting excellence - Phone:(651)281-1200 • (800) 925-1122 Fax (651)281-1298 • TDD (651)281-1290 www.lmcit.lmnc.org THING S TO THINK ABOUT WHEN RENEWING YOUR CITY'S WORKERS' COMPENSATION COVERAGE The LMCIT workers' compensation program is specially designed for Minnesota cities. LMCIT's coverage is unique because it picks up some related risks that standard workers' compensation insurance policies don't cover. This program also offers a number of coverage and premium options, deductibles and credits. LMCIT tries to make buying coverage for the city's workers' compensation exposures as simple and straightforward as possible, but there are still a number of decisions the city needs to make in renewing its work comp coverage. This memo is intended to serve as a guide for cities and agents when thinking about purchasing or renewing work comp coverage. BOARDS AND COMMISSIONS Elected officials Unlike city employees, elected officials are not automatically covered by the work comp law. Cities wishing to cover elected officials need to pass an ordinance or resolution to make the elected officials "employees" for purposes of work comp coverage. If the city does not pass the resolution, a city official that is injured while on city business wouldn't receive any work comp benefits from the city. This mostly affects mayors and council members, but it could also apply to clerk, treasurers, and other officers in cities where those are elected positions. The 2007 premium rate for mayors and council members is $.18 per$100 of payroll. This rate is applied to the greater of either the official's actual salary or an imputed salary of$70 per week. In case of injury, an elected official would receive the same work comp benefits as anyother city employee. Indemnity benefits would be based on the sum of his/her earnings from his/her regular employment plus the actual salary (if any) s/he receives from the city. An alternative to work comp coverage for elected officials is to purchase LMCIT's board member accident coverage. Under this option, cities can provide more limited benefits to council members injured or killed in the course of performing their duties. Accident policy rates are $12.75 per person per year. Benefits are paid for death or short-term disability. This program was originally developed a number of years ago as a low-cost alternative to work comp for elected officials. However, LMCIT has reduced the cost of work comp for elected officials very n minimal. substantially since then, so the cost advantage of the accident coverage option is ow Here's a summary comparison of the two ways cities can cover elected officials through LMCIT: LMCIT elected officials work LMCIT elected officials accident comp coverage coverage Premium cost $.18 per $100 of actual payroll or $12.75 per person per year imputed salary Coverage benefits • Death • Death • Short-term disability • Short-term disability • Loss of wages • Rehabilitation • Medical expenses • Permanent disability For more information about coverage for elected officials, refer to the "Coverage for Injuries to Elected and Appointed Officials"memo. Members of separate administrative boards creates pursuant to statute or charter can also be administrative boards that the city ea p Members of adm y tes covered by workers compensation in the same way as elected officials if the city passes the appropriate ordinance or resolution. Common examples of these types of boards include planning commissions, housing and redevelopment authorities,port authority boards, EDA boards,utilities commissions, park boards, and hospital or nursing home boards. The accident coverage alternative is also available for these positions. For more information about coverage for members of separate boards, refer to the "Coordinating Coverages for Separate City Boards and Commissions"memo. Employees of separate administrative boards In some cases, the city may prefer that entities which are managed by a separate administrative board have their own work comp coverage separate from the city. HRAs, EDAs,port authorities, utilities commissions, and hospital or nursing home boards are examples. Alternately, these employees can be included under the city's general coverage. Having separate coverage may make it easier to allocate costs appropriately between the two budgets. Another reason cities sometimes choose to use separate coverage is so each operation stands on its own for purposes of the experience modification calculation. I.e., with separate coverage, the utilities commission's employees losses won't affect the city's experience modification, and vice versa. On the other hand, by separating the two,the city may lose some benefit of the volume discount on premiums. 2 LMCIT can provide the coverage either way,but the important thing is to make sure that all parties involved are clear on what the intent is. Note that employees of an utilities commission, HRA, EDA, port authority, or hospital or nursing home board are not automatically covered by the city's LMCIT work comp coverage unless that board is specifically listed on the information page of the coverage document. Joint powers boards If a joint powers board has its own employees, it needs work comp coverage. Any joint powers board which has at least one city as a member is eligible for LMCIT work comp e. joint can provide that coverage either by issuing separate coverage g to the� nt p owers board, or by adding the joint powers board as a covered employer on the city's LMCIT work comp coverage. Advisory boards Unpaid members of advisory boards that do not have legal decision-making authority are not eligible to be covered by work comp. However, cities may obtain board accident coverage from LMCIT for members of advisory boards at the same rate as for administrative boards. VOLUNTEERS Volunteers considered employees Certain volunteers are defined by statute as employees for purposes of work comp coverage. These include volunteer firefighters, ambulance attendants, first responders, law enforcement assistance volunteers, and civil defense volunteers. These volunteers are entitled to receive work comp benefits if they are injured while performing volunteer services for the city, and are covered under the city's regular work comp policy. Volunteers in an Emergency City volunteers at work during an emergency are entitled by statute to work comp benefits under a city's policy. Emergency city volunteers must be registered with the city and work under the direction and control of the city. LMCIT does not charge any additional premium for this work comp exposure. (Like other city volunteers, emergency volunteers are also automatically "covered parties" under the city's LMCIT liability coverage.) For more information, refer to the "Providing Assistance in Emergencies: Coverage and Liability Issues"memo. Other city volunteers Other city volunteers are not considered employees and are therefor not covered by workers' compensation. For these volunteers, LMCIT offers an optional volunteer accident coverage, which provides some limited"no-fault"benefits for volunteers injured while working for the city. Volunteers under this program receive limited death, disability and impairment benefits. The city can also add coverage for up to $1,000 of medical costs for an additional charge. This 3 coverage could help avoid litigation in cases where the city may be at fault, and it also provides some protection for people donating their time and effort to city projects. Volunteer accident coverage provides blanket coverage for all city volunteers working under city direction and control, such as coaches and instructors in recreation programs, or volunteers working on city-sponsored festivals or celebrations. The cost of volunteer work comp coverage is based on the city's population, with a basic annual charge of$.10 per capita subject to a minimum premium of$150 and a maximum premium of$1,500 annually. The charge to add volunteers working on a construction project is $300 per project. For more information, refer to the"Accident Coverage for City Volunteers"memo and the "Covering the City's Volunteers" memo. PREMIUM OPTIONS LMCIT work comp members have a number of premium options as well as an option to close- out retro coverage from previous years. Members also have the option of using a managed care provider for the medical management of employees injured while at work. Regular Premium Under the regular premium option,the City's premium is calculated based on City payroll, by class. The premium is then adjusted by an experience modification factor, which reflects the City's previous loss experience. In the experience modification process, claims in the oldest three out of the past four years are considered. In other words, the most recent past year is not considered. If a city chooses the regular premium option, premium payments are the City's only responsibility or liability. The regular premium option is a"fully insured" option for the City to elect. Retrospective rating Under LMCIT's retro-rating plan, a city's final premium costs reflects its own, actual loss experience for the year. Cities with standard premiums of$25,000 or more can if they wish select one of three retrospective options,so that each city may select the amount of risk it wishes to retain. Retrospective rating is a form of risk retention. The final premium under a retro is a function of the city's own losses, so a good safety program is important if you're using a retro. With good loss experience, a retro can save the city significant money over the long run. Of course the city is also subject to possible premium increases if it experiences a lot of injuries or a single big loss. Cities that select a retrospective rating option pay a deposit premium to LMCIT at the beginning of the agreement period. Six months after the end of the agreement year,the city's premiums are adjusted up or down based on the city's actual incurred losses for that year. That adjustment is repeated annually until all claims from the agreement period are closed. 4 Before selecting retro rating, it is often helpful to do a"what if" calculation of what the city's premiums would have been for each of the past few years if the city had had a retrospective rating plan in place. This can be a useful tool for cities evaluating retrospective rating options. A city that's using a retro option should annually review that decision to make sure it still makes sense for the city. A good time for that review is when you receive the annual adjustment bill or refund, about six months after the city's expiration date. The adjustment mailing includes the relevant loss and premium data, so you'll have the information you need and plenty of time to review and make an informed decision for the upcoming renewal. Especially in your first year under a retro, it's a good idea also to look at your current-year losses after nine or ten months to see how you're doing and whether you want to continue with the retro at your renewal. A couple questions to ask when reviewing the retro option: • Are the funds available to cover the city's potential costs? Remember the even a single serious injury be expensive enough to push the city's cost to the maximum for the Y cou e ex p year. Keep in mind too that claims from prior years sometimes re-open or increase in cost,which means that the city can owe addition amounts for prior years as well. To use a retro is to retain risk, and when you retain risk it's critically important that that risk be i funded—i.e., plan have a lan for where the funds would come from to cover the city's potential obligations under the retro. • Does the retro-rating option still make sense for the city? Are you still comfortable trading off certainty in costs for some potential savings? In light of your history and your safety program, are you reasonably confident that you'll be able to keep employee injuries down enough to save money in the coming year? For more information about the retrospective rating options, refer to the "Workers' Compensation Retrospective Rating Options" memo. Retro close-out option After five years participation in a retro program, cities have the option to close out retro-rated coverage from previous years. If a city closes out the retro, no further adjustments are then made to the city's premiums under the retro-rated formula, regardless of what future changes there may be in the city's paid or incurred losses. The charge for the close-out is a percentage of the city's coverage year's incurred losses for the covera ear in question. You may call Barb Meyer at 651-215- 0 o se-out 4173 to calculate your city's close-out charges. For more information about the retro close-out refer to the "Workers' Compensation Retro Close-Out Option"memo. Deductible options Under a deductible option, the city pays lower premium in return for agreeing to reimburse LMCIT for paid medical losses up to a set deductible. If the city selects a deductible option,the deductible applies per occurrence to medical costs only. There are six deductible options ranging from a$250 deductible with a 2.0% premium credit to a$10,000 deductible with an 18.5%premium credit. 5 Deductibles do not affect the experience,modification calculation. Even though under a deductible option the city reimburses LMCIT for certain medical costs, those costs are still included in calculating the experience modification. Like the retro-rating options, deductibles are a way of retaining risk, so if the city uses a deductible option it's important to fund that risk. Remember that the deductibles apply per occurrence, and you need to be prepared for the possibility that you'll have multiple occurrences During the year. For more information on deductible options, refer to the "Workers' Compensation Deductible Options"memo. Managed care option Cities that enroll with a state-certified managed care organization(MCO) receive a 2%premium credit on their work comp coverage. MCOs attempt to reduce the total costs of work comp claims by providing care in a network setting, establishing cost effective treatment protocols, and working to return the employee to work as soon as possible. If the MCO is successful in reducing loss costs, the city would see additional savings in the form of an improved experience modification. LMCIT has been monitoring cities' experience with MCOs for several years. The results are not clear-cut,though the most recent review suggests that managed care may be producing at least some overall savings for some cities. There are now only three certified MCOs in Minnesota: Corvel, which is the one that cities have used most often; Health Partners, which several cities use; and Intracorp/Araz. Some factors to look at in selecting an MCO are whether the MCO has network providers in their area; the MCO's fees and charges; and whether the MCO's overall approach and philosophy matches the city's. For a list of certified MCOs, contact the Department of Labor and Industry at 800-342- 5354 or www.doli.state.mn.us. Non-smoker credit for police and firefighters LMCIT offers member cities a 10 percent rate credit for non-smoking police and firefighters. To qualify for the credit, the city must obtain written statements of non-smoking from at least 90 percent of the members of the department. The statement must be signed and dated, and must state that the individual does not smoke and has not smoked within the previous six months. LMCIT gives this discount because several of the diseases presumed by statute to be job-related for firefighters and police officers—various heart diseases, lung diseases, and cancers—are also related to smoking. Fire or police departments with very few smokers represent a lower risk for claims for heart disease, lung disease, or cancer. For more information on how this credit works, refer to the "Workers' Compensation for Volunteer Firefighters" memo. 6 Comp Time Prey. Yr 06' 07' 08' Holiday Overtime 07' + 08' earings Council David Beaudet 3,275 3,275 $ 6,550 $ 6,000 Les Abrahamson 2,775 2,775 $ 5,550 $ 5,000 Jack Doer 2,775 2,775 $ 5,550 $ 5,000 Mary McComber 2,775 2,775 $ 5,550 $ 5,000 Mark Swenson 2,775 2,775 $ 5,550 $ 5,000 Total $ 28,750 $ 26,000 9411 Part Time Parks John Sortedahl 1,150 $ 1,150 Jay Sortedahl 1,200 $ 1,200 Nathan Piekert 1,276 $ 1,276 Mike Hoffman 2,850 1,176 $ 4,026 Calvin Cloutier 2,550 $ 2,550 Total $ 10,202 9102 $ 5,101 9016 $ 5,101 Police New Guy 21,361 22,002 2,500 500 $ 46,363 $ - Michael Hausken 37,726 38,858 3,468 1,833 $ 81,885 $ 78,269 1.05 Lindy Swanson 45,445 46,808 2,010 $ 94,262 $ 90,189 1.05 Kenneth Anderson 33,275 34,273 2,588 4,427 $ 74,563 $ 72,003 1.04 Paul Hoppe 37,726 38,858 3,601 499 $ 80,683 $ 77,232 1.04 Fred Kropidlowski 33,275 34,273 3,294 366 $ 71,208 $ 68,746 1.04 Brian DeRosier 33,657 34,667 3,335 1,310 $ 72,969 $ 70,559 1.03 Joseph Croft 32,970 33,959 3,235 5,474 $ 75,639 $ 73,001 1.04 David Kisch 32,970 33,959 3,335 716 $ 70,980 $ 71,853 0.99 Sandra Kruse-Roslin 25,071 25,823 108 $ 51,002 $ 48,726 1.05 Total $719,553 7720 Office Staff Gary Brunckhorst 29,974 30,873 1,182 $ 62,030 $ 57,657 1.08 Judy Hoist 43,003 44,293 1,654 $ 88,950 $ 85,102 1.05 Julie Hultman 27,519 28,345 161 $ 56,024 $ 53,587 1.05 Eric Johnson 45,180 46,535 - $ 91,715 $ 86,363 1.06 Jennifer Thoen 18,379 20,634 700 $ 39,713 $ - Judy Tetzlaff 20,197 22,675 $ 42,872 $ - Total $381,304 8810 Building Insp. Jimmy Butler 35,985 37,065 $ 73,050 $ 69,866 1.05 9410 Breakdown Public Works Jeff Kellogg 29,099 29,972 8,671 $ 67,742 $ 64,927 1.04 5506 32,528 Andrew Kegley 22,122 23,241 4,697 $ 50,060 $ 41,449 1.21 7520 120,871 Tom Ozzello 43,397 44,699 584 $ 88,680 $ 84,026 1.06 7580 73,524 Mark Robertson 25,041 25,792 4,451 $ 55,284 $ 50,912 1.09 7720 719,553 8810 381,304 Total $261,765 9102 39,944 Public Works Breakdown 9410 73,050 Andrew $ 50,060 9411 28,750 9102 8% 5% $ 211,705 34,843 Parks 9016 5,101 5506 50% 30% 19,439 Streets 7520 30% 20% 120,871 Water 1,474,625 7580 7% 40% 73,524 Sewer 9410 5% 5% 13,088 Storm Sewer $ 1,474,625 10,202 Parks Workers League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 Phone (651)215-4173 Information Page 1. The "City" RENEWAL Agreement No.: 0200072920 OAK PARK HEIGHTS, CITY OF PO BOX 2007 t r i,� - "City" is: x City OAK PARK HEIGHTS MN 55082 ° - i `� _ Joint Powers Entity Other(describe) 2. The Agreement Period is from 12:01 a.m. 7/07/2006 to 12.01 a.m. 7/07/2007 at the "City's" address. 3. A. Workers' Compensation Coverage: Part One of the Agreement applies to the Workers' Compensation Law of any state of the United States of America and the District of Columbia. B. Employers Liability Coverage: Part Two of the Agreement applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury-Each Occurrence $1,000,000 Bodily Injury by Disease-Agreement Limit $1,000,000 C. Part Three of the Agreement applies to Infectious Disease Diagnostic Testing. D. Part Four of the Agreement applies to Peace Officers' Posttraumatic Stress Syndrome Benefit. E. This Agreement includes these amendments and schedules: 4. Retro-rating option selected? Yes x No 5. Elected Officials Covered? Yes Boards and Commissions Covered (List) NONE 6. The premium for this Agreement will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rates Entries in this item, except as specifically provided Estimated Estimated Total Per$100 of Code elsewhere in this Agreement; Do not modify any of the Annual Annual Remuneration No. other provisions of the Agreement Premium Remuneration SEE ATTACHED SCHEDULE FOR DETAILS Manual Premium 41275. Experience Modification .78 9080. Standard Premium 32195. Managed Care Credit 0% Deductible Credit .0 % Agent: 411709883 592.22 Premium Discount 2584. 00874 FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS Net Deposit Premium 29611. 232 S LAKE ST FOREST LAKE MN 55025- 8/02/2006 LM 4670(12/99) League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 (651)215-4173 The "City" Agreement No.: 0200072920 Agreement Period From: 7/07/2006 OAK PARK HEIGHTS, CITY OF H 1 ) To 7/07/2007 PO BOX 2007 t OAK PARK HEIGHTS MN 55082 CONTINUATION SCHEDULE FOR INFORMATION PAGE REMUNERATION RATE CODE DESCRIPTION EST. PREM 19828. 7.05 5506 STREET CONSTRUCTION 1398. 123926. 3.04 7520 WATERWORKS 3767. 74356. 4.03 7580 SEWAGE DISPOSAL PLANT 2997. 715608. 4.05 7720 POLICE 28982. 378922. .60 8810 CLERICAL OFFICE EMPLOYEES NOC 2274. 4820. 2.54 9016 SKATING RINK OPERATION 122. 22169. 3.21 9102 PARKS 712. 83307. 1.10 9410 MUNICIPAL EMPLOYEES 916. 26000. .41 9411 ELECTED OR APPOINTED OFFICIALS 107. Manual Premium 41275. Agent: 411709883 00874 : FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS 232 S LAKE ST FOREST LAKE MN 55025- 8/02/2006 LM 4680(8/99) L71°Pague Milln"°ta c League of Minnesota Cities LMC War Insurance Trust 145 University Avenue West,St Paul,MN 55103-2044 (651)2811200 • (800)925-1122 Fax:(651)281-1298 • TDD:(651)281-1290 www.lmnc.org MINNESOTA WORKERS' COMPENSATION NOTICE OF RENEWAL This information is provided to assist you in understanding your workers' compensation coverage and renewal options. Please read all the information carefully before making selections for the next coverage period. The following information is included: • Renewal Data form • Copy of previous year's coverage selection and premium information page • Risk management memorandum: Things to Think About When Renewing Your City's Workers' Compensation Coverage If you have additional questions about the coverage options available to your City,please contact the League of Minnesota Cities Insurance Trust: Barb Meyer,Policy Services Technician Mike Wozniak, Underwriting Manager Phone:651-215-4173 Phone: 651-215-4090 Fax: 651-281-1298 Fax: 651-281-1298 Email: bmeyer2 @lmnc.org Email: mwozniak @lmnc.org Deb Anger, Account Manager Ann Gergen,Associate Administrator Phone: 651-215-4170 Phone: 651-281-1291 Fax: 651-281-1297 Fax: 651-281-1298 Email: danger @lmnc.org Email: agergen @lmnc.org Any of the above listed individuals can also be reached at 800-925-1122. AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER LMCIT LMCRisk Management Information League of Minnesota Cities 145 University Avenue West, St.Paul, MN 55103-2044 Cities promoting excellence Phone: (651)281-1200 • (800) 925-1122 Fax: (651)281-1298 • TDD (651)281-1290 www.lmcit.lmnc.org THINGS TO THINK ABOUT WHEN RENEWING YOUR CITY'S WORKERS' COMPENSATION COVERAGE The LMCIT workers' compensation program is specially designed for Minnesota cities. LMCIT's coverage is unique because it picks up some related risks that standard workers' compensation insurance policies don't cover. This program also offers a number of coverage and premium options, deductibles and credits. LMCIT tries to make buying coverage for the city's workers' compensation exposures as simple and straightforward as possible, but there are still a number of decisions the city needs to make in renewing its work comp coverage. This memo is intended to serve as a guide for cities and agents when thinking about purchasing or renewing work comp coverage. BOARDS AND COMMISSIONS Elected officials Unlike city employees, elected officials are not automatically covered by the work comp law. Cities wishing to cover elected officials need to pass an ordinance or resolution to make the elected officials "employees" for purposes of work comp coverage. If the city does not pass the resolution, a city official that is injured while on city business wouldn't receive any work comp benefits from the city. This mostly affects mayors and council members, but it could also apply to clerk, treasurers, and other officers in cities where those are elected positions. The 2007 premium rate for mayors and council members is $.18 per$100 of payroll. This rate is applied to the greater of either the official's actual salary or an imputed salary of$70 per week. In case of injury, an elected official would receive the same work comp benefits as any,other city employee. Indemnity benefits would be based on the sum of his/her earnings from his/her regular employment plus the actual salary (if any) s/he receives from the city. An alternative to work comp coverage for elected officials is to purchase LMCIT's board member accident coverage. Under this option, cities can provide more limited benefits to council members injured or killed in the course of performing their duties. Accident policy rates are $12.75 per person per year. Benefits are paid for death or short-term disability. This program was originally developed a number of years ago as a low-cost alternative to work comp for elected officials. However, LMCIT has reduced the cost of work comp for elected officials very substantially since then, so the cost advantage of the accident coverage option is now minimal. Here's a summary comparison of the two ways cities can cover elected officials through LMCIT: LMCIT elected officials work LMCIT elected officials accident comp coverage coverage Premium cost $.18 per $100 of actual payroll or $12.75 per person per year imputed salary Coverage benefits • Death • Death • Short-term disability • Short-term disability • Loss of wages • Rehabilitation • Medical expenses • Permanent disability For more information about coverage for elected officials, refer to the "Coverage for Injuries to Elected and Appointed Officials"memo. Members of separate administrative boards Members of administrative boards that the city creates pursuant to statute or charter can also be covered by workers compensation in the same way as elected officials if the city passes the appropriate ordinance or resolution. Common examples of these types of boards include planning commissions, housing and redevelopment authorities, port authority boards, EDA boards,utilities commissions, park boards, and hospital or nursing home boards. The accident coverage alternative is also available for these positions. For more information about coverage for members of separate boards, refer to the "Coordinating Coverages for Separate City Boards and Commissions" memo. Employees of separate administrative boards In some cases,the city may prefer that entities which are managed by a separate administrative board have their own work comp coverage separate from the city. HRAs, EDAs, port authorities, utilities commissions, and hospital or nursing home boards are examples. Alternately, these employees can be included under the city's general coverage. Having separate coverage may make it easier to allocate costs appropriately between the two budgets. Another reason cities sometimes choose to use separate coverage is so each operation stands on its own for purposes of the experience modification calculation. I.e., with separate coverage,the utilities commission's employees losses won't affect the city's experience modification, and vice versa. On the other hand, by separating the two, the city may lose some benefit of the volume discount on premiums. 2 LMCIT can provide the coverage either way, but the important thing is to make sure that all parties involved are clear on what the intent is. Note that employees of an utilities commission, HRA, EDA, port authority, or hospital or nursing home board are not automatically covered by the city's LMCIT work comp coverage unless that board is specifically listed on the information page of the coverage document. Joint powers boards If a joint powers board has its own employees, it needs work comp coverage. Any joint powers board which has at least one city as a member is eligible for LMCIT work comp coverage. LMCIT can provide that coverage either by issuing separate coverage to the joint powers board, or by adding the joint powers board as a covered employer on the city's LMCIT work comp coverage. Advisory boards Unpaid members of advisory boards that do not have legal decision-making authority are not eligible to be covered by work comp. However, cities may obtain board accident coverage from LMCIT for members of advisory boards at the same rate as for administrative boards. VOLUNTEERS Volunteers considered employees Certain volunteers are defined by statute as employees for purposes of work comp coverage. These include volunteer firefighters, ambulance attendants, first responders, law enforcement assistance volunteers, and civil defense volunteers. These volunteers are entitled to receive work comp benefits if they are injured while performing volunteer services for the city, and are covered under the city's regular work comp policy. Volunteers in an Emergency City volunteers at work during an emergency are entitled by statute to work comp benefits under a city's policy. Emergency city volunteers must be registered with the city and work under the direction and control of the city. LMCIT does not charge any additional premium for this work comp exposure. (Like other city volunteers, emergency volunteers are also automatically "covered parties" under the city's LMCIT liability coverage.) For more information, refer to the "Providing Assistance in Emergencies: Coverage and Liability Issues" memo. Other city volunteers Other city volunteers are not considered employees and are therefor not covered by workers' compensation. For these volunteers, LMCIT offers an optional volunteer accident coverage, which provides some limited"no-fault" benefits for volunteers injured while working for the city. Volunteers under this program receive limited death, disability and impairment benefits. The city can also add coverage for up to $1,000 of medical costs for an additional charge. This 3 coverage could help avoid litigation in cases where the city may be at fault, and it also provides some protection for people donating their time and effort to city projects. Volunteer accident coverage provides blanket coverage for all city volunteers working under city direction and control, such as coaches and instructors in recreation programs, or volunteers working on city-sponsored festivals or celebrations. The cost of volunteer work comp coverage is based on the city's population, with a basic annual charge of$.10 per capita subject to a minimum premium of$150 and a maximum premium of$1,500 annually. The charge to add volunteers working on a construction project is $300 per project. For more information, refer to the "Accident Coverage for City Volunteers" memo and the "Covering the City's Volunteers" memo. PREMIUM OPTIONS LMCIT work comp members have a number of premium options as well as an option to close- out retro coverage from previous years. Members also have the option of using a managed care employees injured for the medical management o f p y ees �ured while at work. Regular Premium Under the regular premium option, the City's premium is calculated based on City payroll,by class. The premium is then adjusted by an experience modification factor, which reflects the City's previous loss experience. In the experience modification process, claims in the oldest three out of the past four years are considered. In other words, the most recent past year is not considered. If a city chooses the regular premium option, premium payments are the City's only responsibility or liability. The regular premium option is a"fully insured" option for the City to elect. Retrospective rating Under LMCIT's retro-rating plan, a city's final premium costs reflects its own, actual loss experience for the year. Cities with standard premiums of$25,000 or more can if they wish select one of three retrospective options, so that each city may select the amount of risk it wishes to retain. Retrospective rating is a form of risk retention. The final premium under a retro is a function of the city's own losses, so a good safety program is important if you're using a retro. With good loss experience, a retro can save the city significant money over the long run. Of course the city is also subject to possible premium increases if it experiences a lot of injuries or a single big loss. Cities that select a retrospective rating option pay a deposit premium to LMCIT at the beginning of the agreement period. Six months after the end of the agreement year, the city's premiums are adjusted up or down based on the city's actual incurred losses for that year. That adjustment is repeated annually until all claims from the agreement period are closed. 4 Before selecting retro rating, it is often helpful to do a"what if" calculation of what the city's premiums would have been for each of the past few years if the city had had a retrospective rating plan in place. This can be a useful tool for cities evaluating retrospective rating options. A city that's using a retro option should annually review that decision to make sure it still makes sense for the city. A good time for that review is when you receive the annual adjustment bill or refund, about six months after the city's expiration date. The adjustment mailing includes the relevant loss and premium data, so you'll have the information you need and plenty of time to review and make an informed decision for the upcoming renewal. Especially in your first year under a retro, it's a good idea also to look at your current-year losses after nine or ten months to see how you're doing and whether you want to continue with the retro at your renewal. A couple questions to ask when reviewing the retro option: • Are the funds available to cover the city's potential costs? Remember the even a single serious injury could be expensive enough to push the city's cost to the maximum for the year. Keep in mind too that claims from prior years sometimes re-open or increase in cost, which means that the city can owe addition amounts for prior years as well. To use a retro is to retain risk, and when you retain risk it's critically important that that risk be funded—i.e., have a plan for where the funds would come from to cover the city's potential obligations under the retro. • Does the retro-rating option still make sense for the city? Are you still comfortable trading off certainty in costs for some potential savings? In light of your history and your safety program, are you reasonably confident that you'll be able to keep employee injuries down enough to save money in the coming year? For more information about the retrospective rating options, refer to the "Workers' Compensation Retrospective Rating Options" memo. Retro close-out option After five years participation in a retro program, cities have the option to close out retro-rated coverage from previous years. If a city closes out the retro, no further adjustments are then made to the city's premiums under the retro-rated formula, regardless of what future changes there may be in the city's paid or incurred losses. The charge for the close-out is a percentage of the city's incurred losses for the coverage year in question. You may call Barb Meyer at 651-215- 4173 to calculate your city's close-out charges. For more information about the retro close-out option,refer to the "Workers' Compensation Retro Close-Out Option"memo. Deductible options Under a deductible option, the city pays lower premium in return for agreeing to reimburse LMCIT for paid medical losses up to a set deductible. If the city selects a deductible option, the deductible applies per occurrence to medical costs only. There are six deductible options ranging from a$250 deductible with a 2.0% premium credit to a$10,000 deductible with an 18.5% premium credit. 5 Deductibles do not affect the experience modification calculation. Even though under a deductible option the city reimburses LMCIT for certain medical costs, those costs are still included in calculating the experience modification. Like the retro-rating options, deductibles are a way of retaining risk, so if the city uses a deductible option it's important to fund that risk. Remember that the deductibles apply per occurrence, and you need to be prepared for the possibility that you'll have multiple occurrences During the year. For more information on deductible options, refer to the "Workers' Compensation Deductible Options" memo. Managed care option Cities that enroll with a state-certified managed care organization(MCO)receive a 2% premium credit on their work comp coverage. MCOs attempt to reduce the total costs of work comp claims by providing care in a network setting, establishing cost effective treatment protocols, and working to return the employee to work as soon as possible. If the MCO is successful in reducing loss costs, the city would see additional savings in the form of an improved experience modification. LMCIT has been monitoring cities' experience with MCOs for several years. The results are not clear-cut,though the most recent review suggests that managed care may be producing at least some overall savings for some cities. There are now only three certified MCOs in Minnesota: Corvel, which is the one that cities have used most often; Health Partners,which several cities use; and Intracorp/Araz. Some factors to look at in selecting an MCO are whether the MCO has network providers in their area; the MCO's fees and charges; and whether the MCO's overall approach and philosophy matches the certified contact the Department of Labor and Industry at 800-342- city's. For a list of certi ied MCOs, p Y 5354 or www.doli.state.mn.us. Non-smoker credit for police and firefighters LMCIT offers member cities a 10 percent rate credit for non-smoking police and firefighters. To qualify for the credit, the city must obtain written statements of non-smoking from at least 90 percent of the members of the department. The statement must be signed and dated, and must state that the individual does not smoke and has not smoked within the previous six months. LMCIT gives this discount because several of the diseases presumed by statute to be job-related for firefighters and police officers various heart diseases, lung diseases, and cancers—are also related to smoking. Fire or police departments with very few smokers represent a lower risk for claims for heart disease, lung disease, or cancer. For more information on how this credit works, refer to the "Workers' Compensation for Volunteer Firefighters" memo. 6 08/16/2006 WED 21:51 FAX Z001/001 R INSURANCE BINDER OP ID BA DATE(MM/6/20Y) �C�R�® 08/16/2006 THIS BINDER IS A TEMPORARY INSURANCE CONTRACT,SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM. AMY COMPANY BINDER 0 1441 LMCIT-Berkley Risk Services, 43A07072005 La dmark Insurance Services EFFECTIVE EXPIRATION 232 South Lake Street _ DATE r TIME DATE TIME Forest Lake MN 55025 X AM X 12:D1 AM Brian Alm 07/07/061 12:01 PM 09/07/06 NOON (A/C,,N0,EMt): 651-464-3333 I (AJC,No): 651-464-7596 X THIS 91NDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY CODE: SUB CODE: PER PORING POI ICY 4: SEE REMARKS =Mr' DESCRIPTION OF OPERATIONS/VENICLESJPROPERTY(Including LocaUOn) CUSTOMER ID: OAKPA-1 INSURED City of Oak Park Heights All city property, Autos and Equipment - Judy Holst, Finance Director based on renewal application (2006) 14168 Oak Park Blvd PO Bx 2007 Provided by the city. Oak Park Heights MN 55082-2007 1 COVERAGES LIMITS TYPE OF INSURANCE COVERAGEiFORMS DEDUCTIBLE COINS% AMOUNT PROPERTY - CAUSE30FLOSS BLKT BG/PP 500 per schedl BASIC l J BROAD L J SPEC X Replacement Cost GENERAL LIABILITY EACH OCCURRENCE $1,000,000 "DAMAGE TO s50,000 X COMMERCIAL GENERAL LIABILITY RENTED PREMISES — X CLAIMS MADE E OCCUR MED EXP(Any one person) $1,000 PERSONAL&AM/INJURY $1,000,000. ^GENERALAGGREGATE 51,000,000. RETRO DATE FOR CLAIMS MADE: 07/07/87 PRnnI ICTS-COMP/OP AGG $1,000,000. AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000. Y AUTO DODILY INJURY(Par person) S LL OWNED AUTOS BODILY INJURY(Para denI) $ _ SCHEDULED AUTOS PROPERTY DAMAGE $ ' HIRED AUTOS MEDICAL PAYMENTS 3 NON-OWNED AUTOS PERSONAL INJURY PROT S X $500 DEDUCTIBLE UNINSURED MOTORIST $1,000,000. $ AUTO PHYSICAL DAMAGE DEDUCTIBLE AI I VFNICLFS Li SCHEDULED VEHICLES X ACTUAL CASH VALUE X COLLISION: 500 STATED AMOUNT $ X OTHER THAN COL: 500 OTHER . GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO 01 HER THAN AUTO ONLY:M EACH ACCIDENT S AGGREGATE S EXCESS LIABILITY EACH OCCURRENCE $1,000,000 X I UMBRELLA FORM AGGREGATE $1,000,000. OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: 07/07/87 SELF-INSURED RETENTION $1 O,0 0 WC STATUTORY LIMITS WORKERS COMPENSATION F I.FACH ACCIDENT $ AND EMPLOYER'S LIADILITY E.L.DISEASE-CA EMPLOYEE $ C.L.DISEASE-POLICY LIMIT $ SPECIAL Extends renewal of the following policies: CMC25101, MEL4922 and O'NML3375. FEES S CONIERTIONS vOpen Meeting Lnw Defense Cost Reimbursement - $50,000.; Crime - $100,000. } COVERAGES /5500. ded TAXES -- ESTIMATED TOTAL PREMIUM S NAME A.ADDRESS ( MORTGAGEE ADDITIONAL INSURED !41) LT AN HAY Et LOAN A AUTHORIZE REPRESENTATIVE l 62eprogamm.as. , • ACORD 75(2004/09) NOTE:IMPORTANT STATE INFORMATION ON REVERSE SIDE 0 ACORD CORPORATION 1993-2004 CITY OF OAK PARK HEIGHTS 4a 14168 Oak Park Boulevard No. • P.O.Box 2007 • Oak Park Heights,MN 55082-2007 • Phone:651/439-4439 • Fax:651/439-0574 June 26, 2006 Kate Tipping Landmark Insurance Services 232 S. Lake St. Forest Lake, MN 55025 Dear Kate: Here's the renewal application for the City of Oak Park Heights insurance for 2006/07. Please forward an insurance binder as soon as you are able to do so. Let me know if you need additional information. • Thank you, "Judy Holst Deputy Clerk/Finance Director • Tree City U.S.A. Y _ • IV: '''. ' ' ' , '- .. _ _, I \ 1 - - - r;v r i nsI ,,-I c'1t,' i.'\,,. -I i I{ �, i ) • (- ( - {r1 , , ; '>, ' . •{ • 1 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST LIABILITY COVERAGE -WAIVER FORM • Cities obtaining liability coverage from the League of Minnesota Cities Insurance Trust must decide whether or not to waive the statutory tort liability limits to the extent of the coverage purchased. The decision to waive or not to waive the statutory limits has the following effects: • If the city does not waive the statutory tort limits, an individual claimant would be able to recover no more than $300,000.on any claim to which the statutory tort limits apply. The total which all claimants would be able to recover for a single occurrence to which the statutory tort limits apply would be limited to$1,000,000. These statutory tort limits would apply regardless of whether or not the city purchases the optional excess liability coverage. . If the city waives the statutory tort limits and does not purchase excess liability coverage, a single claimant could potentially recover up to$1,000,000. on a single occurrence. The total which all claimants would be able to recover for a single occurrence to which the statutory tort limits apply would also be limited to $1,000,000., regardless of the number of claimants. . If the city waives the statutory tort limits and purchases excess liability coverage, a single claimant could potentially recover an amount up to the limit of the coverage purchased. The total which all claimants would be able to recover for a single occurrence to which the statutory tort limits apply would also be limited to the amount of coverage purchased, regardless of the number of claimants. Claims to which the statutory municipal tort limits do not apply are not affected by this decision. This decision must be made by the city council. Cities purchasing coverage must complete and return this form to LMCIT before the effective date of the coverage. For further information, contact LMCIT. You may also wish to discuss these issues with your city attorney. • � ;Q ;' ` accepts liability coverage limits of from the League of Minnesota Cities Insurance Trust(LMCIT). ❑ The city DOES NOT WAIVE the monetary limits on municipal tort liability established by Minnesota Statutes 466.04. I< The city WAIVES the monetary limits on tort liability established by Minnesota Statutes 466.04, to the extent of the limits of the liability coverage obtained from LMCIT. Date of city council meeting'3� 3 Y ' / Return this completed form to LMCIT, 145 University Ave. W., St. Paul, MN. 55103-2044 • LMCIT(11/00)(Rev. 11/03) Page 1 of 1 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 145 University Avenue West St. Paul, MN 55103 • (651) 281-1200 APPLICATION FOR: c ( c.w k 44 e. #2-- County: (iJcalLAIrlyk Mailing Address: ( 4I(o d64- 7 Qc. ( cw Ic, t3(v Phone:OS(-(G3gI 44 341 City, State,Zip: da.Qc Pad L {{�{5 / "1 /J SS Oia- 647(o Contact Person: W68 ( Cy lc, (. .)hn So" Title: C; 4.i.# c .cQwv w i sAv CW 2000 Census Population: # P # tttq : y &3 TQt , 3 �9Pen: t.<', SIB 7d Is the applicant a Member of The League of Minnesota Cities? ,jYes ❑No. Submitting Agency: L. ..v cR, wce.v L- I h SRX tJ (-AA- Address: 23 2.. L,eLect,, SA • S • Sty, State, Zip: F (.d.,Qc a, M A 5 5 d.2 5 Telephone: (1051 ) 1440q-3 L , (.-3333 Facsimile: 4:;,5l ) 44,4 - ?5 9 c, Agency Contact: kaZ ( ;( U Is Email Address: 11;-CkX i-a•1vG..TSC ..K'c'}' Date of Council Resolution or Contract Appointing the Agency: AGENT COMPENSATION: X 10% n City Will Compensate the Agent Directly Other Please specify: Standard Deductible: 'ZOO , (Applies to All Lines. Optional All Lines Deductibles are Available.; Current Information on Coverage You Are Applying For: Carrier Policy Type Expiration Date Premium LMLIT 1)ac.16.41. - 7 -D(p cuctorkilomi is 6 LMCITAPP(11/00)(Rev.11/03) Page 1 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST PROPERTY/MOBILE PROPERTY COVERAGE • The General Limit of Coverage per Occurrence is the sum of the estimated replacement costs of the building, contents, property in the open, builders risk property, and mobile property. BUILDINGS/CONTENTS/PROPERTY IN THE OPEN Attach updated schedule of buildings/contents, and property in the open. Please identify any vacant properties on the schedule. MOBILE PROPERTY-GREATER THAN $25,000 Attach updated schedule of mobile property with replacement cost values greater than $25,000. • MOBILE PROPERTY - $25,000 OR LESS Mobile property with replacement cost values of$25,000 or less can be covered with no schedule. There is a flat premium charge. Do you want this coverage? YES ENO CRIME COVERAGE The covenant automatically provides a$100,000 per occurrence limit for crime losses,with no additional premium charge. LMCIT provides coverage for theft, disappearance and destruction-inside, theft disappearance and destruction-outside, and forgery and alteration. The coverage is now a blanket limit wit h n o location limitations. If you need additional limits, please contact your LMCIT Underwriter. • LMCITAPP(11/00)(Rev.11/03) Page 2 of 21 • H a a a " •0 t M sV i O 0 o as 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 fli � U U U h 0 0 Xo U o 1 1 I .V o R . - x $ $ 2 2 2 A 2 2 2 R. z 2 A 2 2 2 2 z 2 Z 0 O N CO rq O. 0 w U a. �JJf w as H r"_ W N p7 'b' M 4' (9 M O O O M u� co �o m P P m fl W 1^ 41 4 0 40 0o 0 m . if. tr1 u) (9 N N M m CO N g 1:114 24.1 a W W v7 • r N H 04 0o W 0h N N N N in '0 N N P CO H W 0 P7 O W .21 h W 0 00 fA '0 p '0 M P OO N H 0O rn• 5 0 N h N m .n . .0 co ch as m .0 h V• ul w .n 0 U W rl CO ^7 i . p a Q q q q q q p p p o O O O O O a o WW U C CO m CO 02 CO 0 as aAa 0) A H H H H a a 0) O p4 a cA 1 47 o 0 q 141 H 2 az 0) � x h a 0G a M O GI Q 2 g x d a H 4 4 a x 0 PI a 0 g # a4 2 a rx a N c� a oe of w o a o z o o p a p� a:e.U a p x g E o 7 0 W d ��"+ a R, 2 2 H 0 m M o , o 2 h m 0 0 u a E 0 E C� p �. n 4 a Y. N d E El 4. N N H N N P a E a 0 m `� a co `O In 0) w a H w N 0 m CO a' 0 pG 0 'Avr-rnglz z. plfv,Aog - t2 r,0 40 o U H X m a Kt 00i N tel a .. a H N 0) 2 U N i .4 0) a N a H H U N a U a 7 a cQ W U ,x W 4 • H 0 .a H H H H H H H w H .. *1 H CO w 0Hq °o 0 0 0 c °o ° ° 4 o O o o Q 0 0 0 0 4 CO 4 © O O o q 0 0 CS O 0 0 0 P U E .w N M w us .o h m rn as .1 N M '0 .n 40 h m rn 0 H 1.4 7 O O 0 0 4 O 0 0 Q 0 H H H .-1 0 H H 0 0 H 02 A'. A 2 4 0 0 0 o Q O 0 0 o Q 0 0 , 0 o 0 0 0 0 ET/60•d s6ZSTB TS9 S3IlI3 NW do 2nod91 S :0ti 9003—PT—NFU 0 I - 0 ; I { >, a o a \ n 0 0 R ) B § u S 0 0 3 / 1 # 1 \ ° } \ , . 04 / a . D k u ■ 8 v . § § k 2 � / / k . M r A o f b b k f k 43 01 m p I i ' f 2 • § k V k 0 2 � 8 PI / XI 10 § b§ H g § E. - - « k, § §; qf A a 0 IA m m 0 ° § g V. U 2 k K g 2 / ; - 18 8 § \ K 2 k 0 o 2 _ 1 4 k 0 H a I 0 § § § • ) 0 a a k 4 ) o ) £ / I' B6ETTB3TS9 S I1IO NW AO 3110U31 9 :ea 9 @-T-F LEAGUE OF MINNESOTA CITIES INSURANCE TRUST WATER AND SUPPLEMENTAL FLOOD COVERAGE APPLICATION • 1. Does the applicant have any locations in a flood hazard area? ✓ti6 If yes, has the maximum amount of NFIP flood insurance coverage been purchased? 2. Please provide the following information for any location where you are interested in the NFIP Supplemental Flood Coverage from LMCIT. Note:NFIP flood insurance coverage must be at the maximum amount of insurance available for the LMCIT Supplemental Flood Coverage to be available. Please contact your Underwriter for further information. 7--- 0a^ !'� > �.✓ n}b �� k� � ` � .t, � fit.- _ .4� � • • LMCITAPP(11/00)(Rev.11/03) Page 3 of21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST PROPERTY Unless specifically named,the following entities are not covered for property coverage. If property coverage is desired, please indicate below. If any of the entities have property coverage elsewhere, please provide details below. •� HOSPITALS OYES LINO RN/A NURSING HOME OYES ONO KN/A HEALTH CLINICS OYES ONO TIN/A AIRPORTS OYES ONO ►`C /A ELECTRIC UTILITY OYES ONO /r /A GAS UTILITY OYES ONO in NIA • STEAM UTILITY DYES ONO !IN/A HRA OYES ONO SUN/A EDA BYES ONO ❑N/A PORT AUTHORITY OYES ONO XN/A T ,.INFO I ATION: 1 ,C{ � C;k...;. C�• ; CY c r C -- ��='f,. Cw; �+ �z.��t� K„..air- — It - v LMCITAPP(1 1/00)(Rev.11/03) Page 4 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST INSTRUCTIONS FOR LMCIT EXPENDITURE WORKS EET • Line I All expenditures—include all operating expenses, capital outlay, capital projects, debt, service (principal and interest)for the following: General Fund `J a 7, -772, Debt Service Enterprise Fund , 3(a 0, S:33 Port Authority Special Revenue Funds Nursing Homes Capital Improvement Funds /i `y 3 7 2"5 Hospitals Airports Clinics HRA Other(please describe) EDA Line II Transfers Out Line III Please list the expenditures for the categories shown on Lines III. a—i). These expenditures may be deducted if LMCIT is NOT providing E &0 Coverage for these operations. Line IV Adjust total expenditures is the total expenditures for those departments and operations that have E&O Coverage with LMCIT. Line V GL Deductions: A. Please list expenditures for the categories shown on Lines V. a—m). These deductions are necessary to subtract expenditures for operations or departments where the exposures are individually rated. B. Work performed by contractors which includes capital projects or services are also subtracted. or Your Information a) Contracted Services—All Operations: Expenditures should be deducted if the services are provided by others and they provide a Certificate of Insurance. b) Debt Services (principal and interest) c-j) Please indicate expenditures for these operations (minus contracted services and debt services) m) Special Deductions: There may be some special deductions that are appropriate. Please list these special deductions or list them with your underwriter. Line VI The operating expenditures are the expenditures that will be used to develop a portion of the liability premium. Individually rated exposures are used to develop the remainder of the final premium. PLEASE ATTACH A COPY OF THE LATEST CPA AUDIT AND/OR THE PROJECTED BUDGET(WHICHEVER REFLECTS THE EXPENDITURES ON THE WORKSHEET.) THIS INFORMATION WILL ASSIST UNDERWRITING IN ANSWERING ANY QUESTIONS WITH REGARD TO THE EXPENDITURES WORKSHEET. • LMCITAPP(11/00)(Rev.11/03) Page 5 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST LMCIT:EXPENDITURES WORKSHEET �pplicant: c4' 44.et. Pouf Ml kG 64+5 , Budget Year ZOO All Expenditures 2 II. Transfers Out 612 III. E&0 Deductions a) HRA b) EDA c) Port Authority d) Nursing Homes e) Hospitals f) Airports g) Clinics h) Utilities(Water, Electric,Gas and Steam) i) Liquor Store Cost of Goods Sold (if included in I.) IV. Adjust Total Expenditures(E&0) V. GL Deductions a) Contracted Services / cry ? ?4) b) Debt Service pZ St LC 33' c) Water Department Only 3 l of -2-Ov d) Electric e) Steam f) Gas g) Liquor(Operating Expenses Only—Do Not Include cost of goods sold) h) Recreation Buildings(Arenas,Sr.Citizens Centers,Ice Arenas) i) Swimming Pools j) Golf Courses k) Individual Purchases which exceed 5%of the adjusted total expenditures (E&0)(List&Describe) I) Operations or departments that have E&O Coverage with LMCIT, but have their own General Liability with another insurance company. m) Special Deductions(List and Describe) Operating Expenditures(GL) 67.5 0 —7 o' LMCITAPP(11/00)(Rev.11/03) Page 6 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST LMCI va TYKES INOWIMT IllApplicant: C,z c- Qc&- pc."i4 64+5 • Budget Year 2 UO 4. All Expenditures v' 67l (.z 1 II. Transfers Out 612 /1. Ill. E&0 Deductions a) HRA b) EDA c) Port Authority d) Nursing Homes e) Hospitals f) Airports g) Clinics h) Utilities(Water, Electric, Gas and Steam) i) Liquor Store Cost of Goods Sold (if included in I.) IV. Adjust Total Expenditures (E&0) V. GL Deductions • a) `15i1, q 94) a Contracted Services b) Debt Service p 347/, � '3 c) Water Department Only d) Electric e) Steam f) Gas g) Liquor(Operating Expenses Only—Do Not Include cost of goods sold) h) Recreation Buildings(Arenas,Sr.Citizens Centers, Ice Arenas) i) Swimming Pools j) Golf Courses k) Individual Purchases which exceed 5%of the adjusted total expenditures (E&0)(List&Describe) I) Operations or departments that have E&O Coverage with LMCIT, but have their own General Liability with another insurance company. m) Special Deductions(List and Describe) �I. Operating Expenditures (GL) LMCITAPP(11/00)(Rev.11/03) Page 6 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST MUNICIPAL LIABILITY- SEPARATELY RATED EXPOSURES • DO NOT CI C9 rY OT LEAVE ANY SPACES BLANK IF NO EXPOSURE PLEASE INDICATE N/A OR NONE C Applicant: 'c cw k- 1{.12.4.0 A- Date Co — 20 O tP 1. Golf course annual receipts: ✓�ca. Number of golf carts rented out: 1",unR- 2. Street mileage: 2 0 (Round to nearest mile, i.e.4.2 miles should be 4) 3. Area (square feet)of Exhibition Buildings, Recreation Centers,Arenas, Auditorium or Community Centers: ✓rOwe- 4. Water Department payroll: /3-7 0 'la Total gallons of water pumped annually: 2 2 f c L :. . 000 • (Round to nearest million, i.e. 2,500,000 should be 3,000,000) 5. Electric Department payroll: �cnti+a 6. Gas Department payroll: 7. Steam Department payroll: 8. Number of powered boats: Horsepower and usage of each: 9. Number of boats and canoes not powered: Explain how they are used: • LMCITAPP(11/00)(Rev.11/03) Page 7 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 10. Municipal liquor store receipts: • Store 1 Store 2 Store 3 On Sale Off Sale 11. Number of seasonal swimming pools: Height of diving boards: 12. Number of inside swimming pools: Height of diving boards: 13. Number of swimming beaches: Height of diving boards: Number of docks and rafts: 14. Number of water slides: Heights: Length Location: Seasonal: Year Round: 15. Does the pool(s)comply with the Minnesota Department of Health revised Chapter 4717, Public Swimming Pool Rules effective January 4, 1995, concerning water depth requirements for diving boards and pool decks? Yes❑ No❑ 16. Number of staff attorneys: Inuw.g. Do you want coverage to be excluded? Yes❑ No❑ Additional Information May be Necessary II17. Does the Applicant want to exclude medical payments? Yes❑ No LMCITAPP(11/00)(Rev.11/03) Page 8 of21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST MUNICIPALITY QUESTIONNAIRE DO NOT LEAVE ANY SPACES BLANK, IF NO EXPOSURE PLEASE INDICATE N/A OR NONE Applicant: C 47 die 04,1 4 1)aw 1�- 6"C'f `� Date (o - 20 - 0 (a 1. Does the applicant own or operate any of the following? �,' � .. _� .�. ,�' r rz,n9r,t. t.,,';�3 � ,,,r„? ,^�s�. �� � n.Y 5 €i �e.� `, w'`":r r�,�' �%,^ �., ' ni`" c yF 4 1+� 3r s�&�4a, Yg xzy ,� '��"sYsk' �� + ' ,r��r Av` ; Si � �� fi �t�,�.,.,f ���ra�.....$@ r .;,.. ��y�,”. % ✓ �' n ".dt- r;/.>. � ,c f.�s r?�;. fs .xgri .,,'' r,.,n. 7'.%,✓ .,M>. },?,.. :� ''�sxE '�< b'k m<..,.4 ;'"` �„' r e�' ';y1 5 L,�u � � 'n.k''y�>`�� �x�n.a! #, �',., ! ,z,✓ �sf � ,� .,,^ � +��?�.,,,C'� !` �.x:;,,r�..i�y`� aY�.�p' 2 ✓ ..�a�'� 6> '� x,v '� ✓��.,,„` e�� � ��.fps ;r�, f� � � ? �,s��t � n�xw s';�G'. i:'rX .f'f r L ,,.,#.w+�`�/.�� f.y �,� ✓1�� kfiFt .4 �� '.,%H � � ',�' Ev�yf� � C”3�'k� �Y�k� � �' f � '37;:�^AE s , a @(";'-'6)0'1401d4 Ag a �y)q ° t . aO a c nd F�'v xx Hospitals ❑ Yes No ❑Yes ❑ No Nursing Homes ❑ Yes M No ❑ Yes ❑ No Health Clinics ❑ Yes No ❑ Yes ❑ No IAirports ❑ Yes ► No ❑Yes ❑ No •omments: Municipal Liability, except for bodily injury, property damage or personal iniury, is automatically provided for the applicant and the other Governmental Body or Entity. If you do not want coverage please notify LMCIT. ** These questions are intended to analyze the coverages provided by the other insurance companies. These other policies must provide bodily injury, property damage or personal injury coverage to the applicant and the other Governmental Body or Entity. LMCITAPP 11/00 (Rev.11/03) Page 9 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 2. A. Damages arising out of the following activities are excluded unless such board, commission, 411 authority, or agency is named in the Declarations, in which case the city will also be covered to the extent of coverage provided under this covenant to the named board,commission, authority or agency for damages arising out of the activities of the respective named board, commission, authority or agency. Please designate the activities you want covered below. B. If the Governmental Body or Entity has purchased coverage elsewhe the City needs to evaluate their exposures and the coverage that they need. 1) Is the city named as an additional insured on the other polic and for what coverage? 2) Does the city want coverage from LMCIT for these activities? PLEASE CONTACT LMCIT FOR ASSISTANCE. ADDITIONAL PREMIUM MAY BE NECESSARY. rqq e s £ �r ✓ -.er 1 1 fr C.'kl Gas Utilities Commission El Yes XNo Questionnaire Needed Electric Utilities Commission ❑ Yes 'No Questionnaire Needed I Steam Utilities Commission El Yes KNo Questionnaire Needed Port Authority ❑ Yes No Need Full Details •ing& Redevelopment Authority ❑ Yes 'No Need Full Details IEconomic Development Authority ,'Yes ❑ No 6trz2 O Need Full Details Area or Municipal Redevelopment [� Yes J No Need Full Details Authority i Municipal Power Agency ❑ Yes KNo Need Full Details IMunicipal Gas Agency ❑ Yes No Need Full Details LMCITAPP(11/00)(Rev.11/03) Page 10 of21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 3. A. Damages arising out of the following activities are excluded unless the agency or board is 1 specifically named in the Declarations. Please designate the activities you want covered below. B. If the Governmental Body or Entity has purchased coverage elsewhere the City needs to evaluate their exposures and the coverage that they need. 1) Is the city named as an additional insured on the other policy and for what coverage? 2) Does the city want coverage from LMCIT for these activities? 1r .:.:: :r,° . z �x'r« .�'u._. ,s�.�.;: r.' ,,.r.., z5. F ''.F24 ...,LaA ,,,r..., ,�,... ,......,...w,. Welfare or Public Relief Agency ❑Yes „ "No Need Full Details School Board ❑ Yes ■/ No Need Full Details 4. Does the applicant operate a dump or landfill? What type of material is deposited there? Is the area fenced to keep out the public when closed'? Is the area attended during open hours? 5. Does the applicant own or operate a marina? h� If operated by others, please indicate and advise if the applicant is named as an additional insured on their policy and the policy limits provided. Is coverage desired? Yes ❑ No ❑ If coverage is desired, full details must be submitted. • LMCITAPP(1 1/00)(Rev.11/03) Page 11 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 6. Dams classified as Class I or Class II by the Commissioner of the Department of Natural Resources or any dike, levee or similar structure-(Failure or bursting is excluded.) A. Age of Dams: Inspected regularly: Yes ❑ No ❑ ✓ ,(e)`' By Whom: Height of dam above reservoir: Height of dam above the bottom of spillway: Width: Is the dam fenced to keep the public off? Acre feet of water dam has been designed to retain: acre feet K.(a. B. Age of Dike or Levee: Height of Dike or Levee: Construction Material of Dike or Levee: Acre feet of water Dike or Levee has been designed to retain: acre feet Who built the Dike or Levee? Is the Dike or Levee inspected regularly? By Whom: • 7. Describe any large construction projects anticipated for this coming year. 8. Parks and Playgrounds A. Description (including area)of each park or playground: 5 *- u,4 -c.L ear./; B. Description of playground equipment on each: ` U Z e•ce • LMCITAPP(11/00)(Rev.11/03) Page 12 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 9. Does the applicant operate any aeration devices in the winter to keep an area of local ponds, lakes or rivers ice free? 10\6 If so, please give full details and precautions taken. 10. Special Events/Risks Coverage is excluded for several Special Events/Risks. Please review your covenant and contact your LMCIT Underwriter for additional information. Optional coverage may be available. Does the applicant own, operate or sponsor any of the following? If ves, please provide details. Automobile, mobile equipment, snowmobile or motorcycle in any racing, pulling or speed or demolition contest or in any stunting event. This would include go cart tracks, mudder courses, tractor pulls. (Excluded) Dies 'No • B. Amusement devices,with a power motor greater than 5 H.P (Excluded) ['Yes cNo C. Beer booths (Liquor Liability is excluded. Refer for consideration) [Yes ONo D. BMX tracks Eyes ` jNo E. Climbing Wall Eyes gNo F. Dunk Tanks Eyes No G. Festivals, parades and exhibitions Eyes No H. Fireworks (Excluded. Refer for consideration.) Eyes No I. Rodeos (Excluded) Eyes 0 No J. Skateboard Parks Eyes No K. Ski jumps, ski lifts and tow ropes Eyes /i o L. Toboggan or Tubing Slides Eyes ■No M. Trampolines Eyes o If any of the above are operated by others, please advise if the applicant is named as an additional insured and the policy limits provided. (Continued next page) • LMCITAPP(11/00)(Rev.11/03) Page 13 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 10. Special Events/Risks (continued) • Details: 11. Firefighters Payroll of paid firefighters: IACr^R-• Number of volunteers: N.U.R. Number of fire trucks: Describe any fund raising activities or celebrations by the firefighters or relief associations: 12. EMT's and Paramedics • Number of rescue trucks: Number of ambulances Number of emergency runs: Number of convalescent runs: Number of EMT's: Number of EMT-A's: Number of paramedics: Is there radio contact with hospital doctors? Describe any EMT type losses: • LMCITAPP(11/00)(Rev.11/03) Page 14 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 13. Law Enforcement i* ►f! 'Oement ol p i r 0 PEg4 ►Ll'� �cur Number alai orifoeceitt vet*I`e : Number of Employees by class: la s A(FN11-t9me) A(Part-Time): 0 Class B: 0 Class C: Class D: 0 Class E: Class F: 0 Description of classes. A=Armed with arrest power B = Unarmed, no arrest power C = Non-officer employees D =Auxiliary police E=Voluntary unarmed F=Voluntary armed Describe any law enforcement type losses: hc1vnQ Describe any jail or detention facilities maintained: wit, GD LtAASect Gtr:A•cJd .t. i Maximum holding period: & a O c 2 pr�,�• 14. Grandstands and Stadiums A. Number and location of each: ?AWL, B. Seating capacity: Ite O II . C. Type of construction: D. Permanent or temporary: eta w,cur. ' 15. Wharf or Docks-Describe: F1Gw¢ • LMCITAPP(11/00)(Rev.11/03) Page 15 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 16. Street or Road Construction or Maintenance • . �a e►tt".t '. / (2Z) How much work is sublet to others? Q a c*v�a1± 1 f t Are Certificates of insurance obtained indicating adequate limits?v 1C4 Is any blasting done? v. 17. Please describe any contractual agreements the applicant has entered into such as: A. Mutual aid: 0013et.4n Co(AAA-1 B. Police or fire protection: I?j p,/4 C. Other. Describe: 18. Joint Powers Boards are not covered. However, they may be considered for coverage by submitting full details in a separate application. IMPORTANT! Coverage is not bound or in effect until you receive • written acceptance from LMCIT. 19. Do you routinely get Certificates of Insurance from all independent contractors? 20. Does the applicant provide a fire alarm or burglar alarm protection system? L46 If so, please give full details. 21. Any other pertinent information not covered above: ■6 • LMCITAPP(11/00)(Rev.11/03) Page 16 of21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 22. Applicant was created in: 1ct 14' (Year) III 1 1 1 23. Names and official titles of the Members of the Board or council of the applicant: Name Official L. brwhaw,s(An CO Lunt. vu J ._ -1;c7 J v" '4 Aka* (4 ..4 C.O icy /`'`rw U__ St..)-c " ScM tA, 24. Fiscal Year *Revenue *Expenditure Fund Balance At Year End 20 O(. Projected Year t Yq7, ' S j?9 /. 9 /0,037,.gi 27 20 05 Current Budget S,j35/1/ / 4,,...-2 q7. 74, „1 I q 71 L?.., 20 O' 1st Prior Actual 'i 735 q7a- yi `Ito'�-11 5/rcOd! G3O 20 O3 2nd Prior Actual (is 0?4 0 S 1 LI 1TO S Y ( 1 oil ip 20 OZ. 3`d Prior Actual ���gZt ��O 4 scio 1 173 717-4‘01 72.0 *These figures should include all funds including governmental, enterprise, miscellaneous special revenue and debt service funds. If desired, you may send photocopies of appropriate sheets from annual financial report. 25. a. Total ar nOlffi f ts1 OOrtg.bonds: / 0 G L749 v b. Latest Moody's and/or Standard and Poors' bond rating: n 1 • LMCITAPP(11/00)(Rev.11/03) Page 17 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 26. Have any of the following situations occurred within the last five years? IIIa. Appropriation or condemnation for which agreed settlements have not been achieved. ❑Yes �No b. Improper or alleged wrongful granting of variances, / \ building permits or similar grants or zoning disputes. EYes 'No c. Wrongful or alleged wrongful approval of building plans, designs or specifications. ❑Yes .No d. Wrongful or alleged wrongful approval of building construction. EYes No e. Allegation of unfair or improper treatment regarding employee hiring, remuneration, advancement or termination of employment. EYes No f. Disputes involving integration, segregation, discrimination or ' violation of civil rights. EYes No g. Any grand jury indictments of any public officials. EYes 'RINI° h. Assault and battery claims made against the municipality or its officials. EYes XNo i. Any riot or civil commotion in the past five years. EYes No j. Any losses or claims occurred involving contractual disputes. EYes o 7. Land-;Use tpktity 0 Number of building permits issued: ,111"/ i Number of variances: Granted 6 Denied / Number of conditional use permits: Granted Denied 0 28. H the City submitted their Comprehensive Plan to the Metropolitan Council for review and comment? Xs Yes ❑No Has the Metropolitan Council reviewed the plan and made their comments? igfres ❑No Are you a participant in the Metropolitan Council Livable Communities Program? )Yes ❑No What year did you join? { q(e 411/ LMCITAPP(11/00)(Rev.11/03) Page 18 of21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 29. Please list the additional covered parties required. L'H T ts— � '. ' �.., a „, , � `�'�, � �6�.��.�� •.� v ,�s: ��is .�` 3. e burr 1� x..`. � s�� €� ADDITIONAL COVERED NAME ADDRESS PARTIES INTEREST • 30. Contracts with a railroad and contracts with the contractor performing the actual railroad construction project needs special attention. Please provide a copy of the contract to LMCIT. This does not apply to easement or side track agreements. Please contact LMCIT before you sign a construction agreement with a railroad or the contractor that is performing the actual railroad construction project. • LMCITAPP(11/00)(Rev.11/03) Page 19 of 21 k. • a W M 0 a W W Z. ED O O. K U a d o 0 41 LI S g 41 n a a s A. V A x a W 2 1- u r.x x K W J x m x x x x = x x .11 x 2 'l. 2. : Z 2: x 2 Z x 2 2 S J O W A.x A W 11 Ed x r w 0 W a 7 3 x W O W C o O O O o o m o O o 0 O O O O O 0 o a �� O• O O O p p O O O O © O O O d T. O N N N .4. ry M M M M H «• e • O O O • • 0 O O . A. N V N N N N 01 01 01 0 9f OP O Al Q a * O O 0 W m m A .. M Z V . 0 40 0 W 0 0 N 1n a N N N M M O1 OP 01 01 Of 10 b b 01 O1 O1 O1 W N N N 01 m N M N N N N M M M M 4 a a W a .6 Iu. H N .VS H m u M H W U {F{ 47 ..1 W m m m m J r Wp m N f00 u W = li d Cr 1 d -, a. a Op. O O O O O a a d A. 6 a a s •O .d .J a a a 6 d d 2: .t X x 2: s s w • W .4 = N J K W .a. O 0 h W 0 W _1 A _ •C .h. ^ A . A A �. 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O W 0 0W } 0 _ {{4 yu J O 9 1 H M J 0 C C 0 o a a a 0 0 x x x W S W W W d' LL xW S 2 F- O W U K 2 d K b fY ILL W LL W 2 W 2 V d Q 0 O K O O O J 21" N N N W 2 4 W u o i 0 W } O O 4 r M oa 0 W 0 r 4 v• 111/ o 2 s W w Z NC A, W O 2 K ✓ w p £Tf£I'd 86ZTTBZTS9 53I1I0 NW dO 3lae-1 9Z:0T 9002-PT-Nff LEAGUE OF MINNESOTA CITIES INSURANCE TRUST AUTOMOBILE LIABILITY AND PHYSICAL DAMAGE •Applicant: CC Li elf out. QaN tG 4-2.t. Q- 1. COVERAGES: A. Liability: Limit: $1,000,000. Combined Single Limit on Bodily Injury and Property Damage 0. PLEASE INDICATE ALL UNREGISTERED VEHICLES ON THE ATTACHED SCHEDULE! PLEASE CLEARLY IDENTIFY, OR PROVIDE A LIST OF ALL UNMARKED POLICE VEHICLES! B. Do you want PIP coverage on the unregistered vehicles?vs.cA. ❑Yes ❑No This is an optional coverage. C. Uninsured and Underinsured Motorists The standard limit is$50,000. Indicate limit desired. (1) ❑ $ 50,000. Uninsured and Under insured Motorist Limit* or (2)X $1,000,000. Uninsured and Under insured Motorist Limit (3) Do you want UM/UIM coverage on the unregistered vehicles? rte.- ❑Yes ❑No This is an optional coverage.. D. Automobile Physical Damage: • The separate"comprehensive" and "collision" coverage options have been replaced by the new"auto physical damage" coverage that covers both collision and comprehensive. 2. Applicants have the option to make their LMCIT Liability Coverage primary for vehicles used by specified individuals or groups in specified circumstances. Plea e •• dicate if you want this optional coverage and provide additional information requested. ❑YesVo If yes, please indicate type of individuals or groups: If yes, please indicate number of individuals: 3. VEHICLE SCHEDULE Refer to the LMCIT Auto Coverage Changes bulletin included in your renewal packet. The applicant needs to submit an accurate listing of vehicles for the renewal. The applicant's premium for auto liability and physical damage coverages for the entire year will be based on the schedule of vehicles the applicant reports at renewal. A. All vehicles are covered for liability. B. All vehicles are covered for physical damage, unless you indicate otherwise. c The listing of ve icles should include only those trailers with a load capacity greater than 2000 pounds. f . are now automatically covered for liability and physical damage. D. -® -01 -tt; ost Is available for an additional premium on Fire Trucks and other high valued vehicles aged 10 years or less. (Indicate unit number and replacement value). E Replapernent cost may bbe considered for an additional premium on units aged 10 years or more with proper documsntatioo of the maintenance history. • F .Ptease nthcate color of Fire Trucks 1=Lime Yellow; 2 =Red; 3=All Others IIattached computer printout provides the most current Schedule. However, recent changes may not show on the Schedule.) LMCITAPP(11/00)(Rev.11/03) Page 20 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST UNREGISTERED VEHICLE SCHEDULE r a 4 9� s%' ��.. mas � . � � ✓ _ �' �.. s r � � �" �' � •s ;�,.la�n ,/'3, :, .,-sv 't' S 6 d-'3 e® °fie« 1 2 3 4 5 6 7 8 9 11 13 14 15 16 17 18 19 20 21 22 23 24 LMCITAPP(11l00)(Rev.11/03) Page 21 of 21 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST PUBLIC EMPLOYEE EISHONESTY OR PUBLIC EMPLOYEE FAITHFUL PERFORMANCE COVERAGE APPLICATION • Limit of Coverage Per Occurrence: (Deductible) • Bond—Employee Dishonesty Coverage: $ 100 /000 . (Standard) • Bond—Employee Faithful Performance Coverage: $ (0G / 000 • (Standard) • Option: The applicant may choose to have employee dishonesty or faithful performance coverage for specified positions. Please contact your LMCIT underwriter for additional information. AUDITS: FREQUENCY: BY WHOM? CPA STAFF AUDITOR OTHER(explain Fully) DATE OF LAST AUDIT: DISCREPANCIES ❑YES C1._3k - 05 NO (If YES,submit copy of audit or auditors comments.) LOSS HISTORY: (LAST 5 YEARS) WILL THERE BE A SUBSTANTIAL INCREASE IN THE NUMBER OF EMPLOYEES DURING THE TERM OF THIS BOND? INTERNAL CONTROLS: 0 1. ARE BANK ACCOUNTS RECONCILED AT LEAST MONTHLY? XYES ❑ NO 2. IS THE PERSON WHO RECONCILES PROHIBITED FROM MAINTAINING BANK ACCOUNT RECORDS? YES ❑ NO 3. ARE ALL PERSONS HAVING AUTHORITY TO MAKE BANK DEPOSITS OR WITHDRA AL PROHIBITED FROM EITHER MAINTAINING RECORDS OR RECONCILING THE BANK ACCOUNT?YES ❑ NO 4. IS COUNTERSIGNATURE OF ALL CHECKS REQUIRED? ,YES ❑ NO ADDITIONAL COMMENTS: • LMCITAPP.PEB(11/97)(Rev. 11/03) Page 1 of 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST WFIC.TtQN Qf RhitPLOYEf4,RY OLJTtES.OR REsPO.NSIV1LITI .This classification under Class A, B and C constitutes the cities personnel as of the date of this application and should include Mayor and Council members. CLASS A EMPLOYEES -All Elecutive Administrative Judicial and Supervisory officials,Department and Division Heads and Assistant Department and Division Heads.All Police Officers'and all officials and employees whose principal duties require them to: 1.) Handle,receipt for,or have custody of money,checks or securities,or account for supplies or other supplies or other property,authorize(or make appropriations for) expenditures;approve,certify,sign or countersign checks,drafts,warrants,vouchers,orders or other documents providing for the paying over or delivery of money, securities,supplies or other property,or serve process,or; 2.) Maintain or audit accounts of money,checks,securities,time records,supplies or other property,or take physical inventories of money,checks, securities,supplies or other property. Patrolmen are classified as"A"Employees under"Faithful Performance"Coverage but are classified as"C"Employees under"Dishonesty"Coverage. _ POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS c. boALA flmact,OzittAitcre J___ Acc a+ ate" ___ Ac!l ,h 5 ,r �t 9 cps r- Xo CLASS B EMPLOYEES All personnel whose principal duties consist of: 1. Inside or outside clerical activities; 2. Office work such as stenography,typing,filing,switchboard operation,business machine operation,etc.; 3. 0 ration of vehicles transporting passengers for cash fare or tickets. POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS CLASS C EMPLOYEES All personnel whose principal duties consist of: 1. Skilled or unskilled labor and craftsmanship; 4. Any teaching capacity in the field of education; 2. Solely the mechanical operation of automotive equipment 5. Outside or field work of a non-clerical nature; 3. Non-clerical activities of the medical or nursing profession; 6. Patrolmen under the"Dishonesty"Coverage POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS POSITION #OF OCCUPANTS colciAN LMCITAPP.PEB(11/97)(Rev. 11/03) Page 2 of 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST EQUIPMENT BREAKDOWN 'fAPPLICATION •APPLICANT: C �• cam,OQ O& -Pu INSPECTION CONTACT AT CITY: t 1-6 k TELEPHONE #: 45i-43cl-4%39 AGENT'S NAME: $�JCt. J iv TELEPHONE#: f'SI - (43.4- 3333 COMPREHENSIVE (INCLUDING PRODUCTION MACHINES) NON-REFERRAL OCCUPANCIES ONLY LIMITS: $ Limit any one accident, is the Property General limit of Coverage per Occurrence or $95,000,000 whichever is less any one accident $ 5,000,000 Business Income and Extra Expense $ 100,000 Service Interruption $ 100,000 Perishable Goods $ 100,000 Data Restoration $ 100,000 Demolition and Increased Cost of Construction $ 100,000 Expediting Expenses $ 100,000 Pollutants $ 100,000 CFC Refrigerants • $ 50,000 Ice Buried Piping 1. Does the applicant currently have Boiler&Machinery coverage? 'Yes No 2. Name of current Boiler& Machinery carrier L MG ( Expiration Date: 7 — 1 - 0 r 3. #t toad any boiler and machinery breakdowns in the past 3 years? 1�1 Yes ❑ No If yes, please provide description and amount. `Ze.40 — ©c 2©a -°,,, ,UFF( - , - o4.6 -- % G- Ask 4. Desired Deductible: ..)0� LMCITAPP.EQUIPBRKDWN(11/03)(Rev.11/05) Page 1 of 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 5. REFERRAL OCCUPANCIES (Limited Coverage) • Important: If the applicant has any of the following exposures,further analysis may be required by LMCIT. Coverage for any of these exposures cannot be bound unless approved by LMCIT. Each exposure must indicate a yes or no response. Special conditions, endorsements, limits and deductibles may apply. Please contact your LMCIT underwriter. A. Refuse burning facility(HBB) ❑ Yes)4No B. Equipment for recovering methane or other gases from a se age treatment plant or landfill,or any other system for producing industrial gases (HBG) El Yes No C. Hospital/Clinic equipment listed below(HBH) ❑ YesXNo 1. CT Scanner ❑ Yes ❑ No 2. MRI Unit ❑ Yes ❑ No 3. PET ❑ Yes El No 4. Linear Accelerator ❑ Yes ❑ No 5. Lithotripter ❑ Yes ❑ No 40 D. Steam or hot water district heating system (HBM) ❑ YesNo E. Electrical Generating EquipmenYes ❑ No Type: XDiesel (HBD) ❑ Other(HBE), describe This does not include emergency back-up generators that serve only a single building or function and are not part of a municipal utility. Special Note: LMCIT can provide equipment breakdown coverage for diesel generating equipment, but not for other types of electrical generation equipment such as steam or gas turbines, wind turbines, or hydro-electric facilities. If the utility has both diesel and other types of equipment, the entire risk must be placed with an equipment breakdown insurance company. 4 LMCITAPP.EQUIPBRKDWN(11/03)(Rev.11/05) Page 2 of 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST EXCESS LIABILITY APPLICATION Lll Applicant: C.', 4 7cw 4-- I k . A- Date: 4 ' Z.O -O fQ Limit of ex ess coverage desired: at"ofie'Qc5� $1,000,000 ❑ 0,00 ❑ $3,000,000 $4,000,000 ❑ $5,000,000 Do you wa t t Excess to apply to the Uninsured and Underinsured coverage provided by the primary covenant? Yes ❑ No If yes, the automobile UM/UIM limits must be$1,000,000. The Excess Covenant does not automatically apply to liquor lia lity. Do you want the excess to apply to liquor liability? ❑ Yes No Special Note: The liquor liability primary limits must be$1,000,000. Employers Liability: Carrier: 14V1,C- IC Limits: I /OC9O ,000 • Policy Number: kW L. Sac.' • Policy Period: 1-1 - O -6 Does applicant now have or contemplate any exposure under: (If yes, attach sheet with payroll figures.) (a) Jones Act or Admiralty Jurisdiction ❑ Yes XNo (b) Federal Railroad Employees Act ❑Yes XrNo (c) Federal Longshoremen's & Harbor Workers Act ❑ Yes ,No To what extent does applicant have primary insurance to cover these exposures? I 1 IF THIS IS RENEWAL, PLEASE INDICATE IF RENEWAL IS TO BE BOUND: 4 YES ❑ NO Note: Coverage is excess of LMCIT coverages only. Some of the coverage is not follow form. i • LMCITAPP.12(11/97)(Rev. 11/03) Page 1 of 1 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST SUBMITTED BY: Q ( ■ ,S • � • •PRODUCER: 14.4±, ADDRESS: 23 2 C.(44.4_ S E U Lr'- det 00 5.5 0 ZS APPLICATION FOR OPEN MEETING LAW DEFENSE COST REIMBURSEMENT AGREEMENT APPLICANT'S INSTRUCTIONS: 1. Please answer all questions. If the answer is NONE, please state NONE. 2. If space is insufficient to provide a complete response, attach a separate sheet. 3. The application must be signed by an authorized representative of the City. Special Note: Please answer all questions. These questions are intended to provide general information only. The information provided will also be used for a proactive loss control procedure if needed. APPLICANT 1. Name of city or other public entity whose city officials are to be covered under the Agreement. • c•, calf O Pam 2. Principal Address: ,) f V 1 r�t( lP �S O CAIC T CAA, (C- ji k∎1 c Gtb■ NA1 4•-■•0, MI4 5 so g2. 3. If Joint Powers entity, identify participants: ■IG • LMCITAPP.OML(11/97)(Rev.11/03) Page 1 of 3 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST CLAIM HISTORY List incidents of threatened or actual open meeting law litigation involving city related individuals in the last five years. For each incident give its approximate date and its resolution, including the penalty imposed, if any, and the amount of attorneys fees incurred in defending the incident. xis ; rY< � 1 i o ' - + , a 3 ,per . e% , �' ( ,y � k1' � . tr �.,.x ,X ¢ , �'.✓�'�iay� c� �''"''' . r� ` a 2. Are you presently aware of any other incidents or situations which! y result in an open meeting law 10 claim or litigation against city related individuals? ❑ YES NO If YES, give details: 3. What action has been taken to prevent future incidents or claims? LMCITAPP.OML(11/97)(Rev.11/03) Page 2 of 3 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST OPEN MEETING LAW . QUESTIONNAIRE 1. Description of orientations and/or training provided for all elected officials (GTS programs, League programs, Handbook for Minnesota Cities, loss control seminars ...)on the subject of the open meeting law: Isdas4411. ow .:ems 1 1 2. Ha e all new members attended the League Conference for Newly Elected Officials? YES ❑ NO 3. Do all officials understand the Open Meeting Law and the Cities'compliance procedures? RYES ❑ NO 4. Description of method of documenting official meetings (written, audio, video, ...): 4,/rtik.R. 6 v i ci4.0 I ' 5. Does legal council attend all official meetings?)eYES ❑ NO If no, describe service relationship with city attorney. 6. Is education provided for the elected officials in the proper policy and procedures? a) Land use decision making: YES❑ NO b) Employment practices: DYES❑ NO 7. Please indicate the percentage of reimbursement of defense costs. ❑ 80% 100% BY: • iv St r d T" ..itl of A or -ed R res t e� '�. n p ugh � .��p ) LMCITAPP.OML(11/97)(Rev.11/03) Page 3 of 3 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST LIQUOR LIABILITY APPLICATION • APPLICANT: AGENTS NAME: TELEPHONE NUMBER 1. Effective Date: Name of Licensee: License# 2. Limits of Liability:$ Per Claim $ Annual Aggregate 3. Receipts: Alcoholic Beverages$ (Past 12 months) $ (Estimated next 12 months) 4. List of locations covered and their operations: Location: Operation: Location: Operation: 5. Underwriting: (A) Has the applicant or any employee,officer or licensee incurred any claim for liquor liability in the past 5 years? ❑Yes ❑ No If yes,explain: , • Is the applicant aware of any incidents which may lead to a claim? ❑ Yes ❑ No If yes,explain: (B) Have there been any fights or assaults inside or outside the locations among patrons in the past year? ❑Yes ❑ No If 9 es,give details: Y Have there been any incidents of any employee,officer,or licensee using reasonable force to remove patrons? ❑Yes ❑ No If yes,explain: (C) Does the applicant provide for their employees to receive formal training in the following areas? Operations? ❑Yes ❑ No Handling of minors? ❑Yes ❑ No Handling of intoxicated customers? ❑Yes ❑ No How often is the training done? By whom? Does the applicant provide any additional training? ❑ Yes ❑ NO If yes,explain: • (D) Has the applicant,or any owner, partner,officer,member of licensee ever had a license revoked, refused,or suspended? ❑ Yes ❑ No If yes,give details: LMCITAPP.LLC(11/97)(Rev. 11/03) Page 1 of 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST (E) Previous Carrier: Exp. Date: Premium 0 Policy Number: Limit of Liability (F) Years in business at this location under current ownership: If under 2 years,give previous experience: (G) Has applicant or employee ever been fined or cited for violations of a law or ordinance relating to sales of alcohol?(After hours,minor,etc.) ❑Yes ❑ No If yes,explain: (H) Normal Open/Closing hours: Mon-Thurs Fri Sat Sun (I) Does applicant have entertainment? ❑ Yes ❑ No If yes;explain: (J) What is the turnover of bartenders? (K) Is there a documentation procedure in place for incidents? ❑Yes ❑ NO If yes,explain: • 6. Do you have any special events sponsored and controlled by the liquor store? ❑Yes ❑ NO If yes, please describe: Coverage is excluded. An endorsement is necessary. Please let us know if you want coverage. 7. Do you have any other special events that is not sponsored or controlled by the liquor store? If yes,explain: Coverage is excluded. An endorsement is necessary. Please let us know if you want coverage. 8. Receipts On-Sale Receipts Off-Sale Receipts Special Events Number of Days By: (Signature and Title of Authorized Representative) • LMCITAPP.LLC(11/97)(Rev. 11/03) Page 2 of 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST NO FAULT SEWER BACK-UP COVERAGE APPLICATION •APPLICANT: AGENTS NAME: TELEPHONE NUMBER 1. Inspection and maintenance program Does the applicant have an inspection and maintenance program? ❑ Yes ❑ No Please describe briefly or attach a copy of the program. 2. Problem area identification procedures Does the applicant have in place procedures for identifying and abating problem areas in the system that may require more frequent inspection or cleaning? ❑ Yes ❑ No Please describe briefly. • 3. Emergency response system Does the applicant have a procedure for providing 24-hour/7 day emergency response to sewer back- ups? ❑ Yes ❑ No Please describe briefly. 4. Inflow and Infiltration Procedures (Storm water getting into the sanitary sewer system) Does the applicant have an active plan to minimize the effect of storm water getting into the sanitary sewer system? ❑ Yes ❑ No Please describe briefly. • LMCITAPP.SEWERBU(1 1/00)(Rev. 11/03) Page 1 of 2 LEAGUE OF MINNESOTA CITIES INSURANCE TRUST 5. Documentation • Does the applicant maintain written records of its normal maintenance and inspections of the sewer system? ❑ Yes ❑ No Does the applicant maintain written records for its cleaning and inspection of problem sewer lines? ❑ Yes ❑ No 6. Planning Does the applicant have capital improvements planning in place to remedy any ongoing problems with its sewer system? ❑Yes ❑ No Please provide details including a description of the plan, availability of financial resources and timetables. Special Note: No fault Sewer Back-up Coverage cannot be bound until the applicant has met the underwriting criteria and has passed a No Fault Sewer Back-up Resolution. By: (Signature and Title of Authorized Representative) 11/ LMCITAPP.SEWERBU(11/00)(Rev. 11/03) Page 2 of 2 Page 1 of 1 Judy Hoist From: Julie Hultman ft: Thursday, June 22, 2006 11:09 AM Judy Hoist Subject: RE: Variance & CUPs for Insurance In 2005, the City granted 9 conditional use permits and denied none. They granted 5 variances and denied 1. Julie From: Judy Hoist Sent: Thursday, June 22, 2006 10:51 AM To: Julie Hultman Subject: Variance&CUPs for Insurance Julie, I'm completing the application for the City insurance renewal and I need a couple of things from you. 1. Number of Variances granted in 2005 and number of Variances denied in 2005 2. Number of CUPs granted in 2005 and number of CUPs denied in 2005. Thanks, Judy • • 6/22/2006 �z I 111 I,I ICI !!! III '" %,,../2._ ,faci. _ _ 00 ,200 a_ 1,.1 e_5rz. - a fi.� ‘.O,3 H,; , I , iii 4 ,S_205 ii t;: fI I V� l i V u i 3._ 0.Ira i i & t d.t tti - /, BO.B Iii Cyy%cytntu-s..... Z- 04,0.00 1 l a o, `l 2 '- 0 !i S DOD.00 t i` rw • u s / 7 5'0.04.) i I ,e....+a.•et�-.�u.+J— Zv 0 oO.00 }!; aq,00a,00 !j! 5-0, OD 4.0e, ,. I ` y—,t- S„e.„✓.,c.X. -.. ._ p-O,o00.Op f t G.--ts. _. /5-2--pOO,ov I 6.44,, 9.1%.1A-.0 G 8'57, o2afd90 - _- I } !-r - _ , y.5-Y, '7W ii 't. ill 1, AO— ; II IIt League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 Phone (651)215-4173 • Information Page g 1. The Cit y RENEWAL Agreement reement No.: 0200072920 g OAK PARK HEIGHTS, CITY OF PO BOX 2007 "City" is: x City OAK PARK HEIGHTS MN 55082 Joint Powers Entity Other(describe) 2. The Agreement Period is from 12:01 a.m. 7/07/2006 to 12.01 a.m. 7/07/2007 at the "City's" address. 3. A. Workers' Compensation Coverage: Part One of the Agreement applies to the Workers' Compensation Law of any state of the United States of America and the District of Columbia. B. Employers Liability Coverage: Part Two of the Agreement applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury-Each Occurrence $1,000,000 Bodily Injury by Disease-Agreement Limit $1,000,000 C. Part Three of the Agreement applies to Infectious Disease Diagnostic Testing. D. Part Four of the Agreement applies to Peace Officers' Posttraumatic Stress Syndrome Benefit. E. This Agreement includes these amendments and schedules: • 4. Retro-rating option selected? Yes x No 5. Elected Officials Covered? Yes Boards and Commissions Covered (List) NONE 6. The premium for this Agreement will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rates Entries in this item, except as specifically provided Estimated Estimated Total Per$100 of Code elsewhere in this Agreement; Do not modify any of the Annual Annual Remuneration No. other provisions of the Agreement Premium Remuneration SEE ATTACHED SCHEDULE FOR DETAILS Manual Premium 41275. Experience Modification .78 9080. Standard Premium 32195. Managed Care Credit 0% Deductible Credit .0 % Agent: 411709883 592.22 Premium Discount 2584. .4 FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS Net Deposit Premium 29611. 232 S LAKE ST FOREST LAKE MN 55025- 8/02/2006 LM 4670(12/99) League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 (651)215-4173 Illke "City" Agreement No.: 0200072920 Agreement Period From: 7/07/2006 OAK PARK HEIGHTS, CITY OF To: 7/07/2007 PO BOX 2007 OAK PARK HEIGHTS MN 55082 CONTINUATION SCHEDULE FOR INFORMATION PAGE REMUNERATION RATE CODE DESCRIPTION EST. PREM 19828. 7.05 5506 STREET CONSTRUCTION 1398. 123926. 3.04 7520 WATERWORKS 3767. 74356. 4.03 7580 SEWAGE DISPOSAL PLANT 2997. 715608. 4.05 7720 POLICE 28982. 378922. .60 8810 CLERICAL OFFICE EMPLOYEES NOC 2274. 4820. 2.54 9016 SKATING RINK OPERATION 122. 22169. 3.21 9102 PARKS 712. 83307. 1. 10 9410 MUNICIPAL EMPLOYEES 916. 26000. .41 9411 ELECTED OR APPOINTED OFFICIALS 107. Manual Premium 41275. • Agent: 411709883 00874 : FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS S 232 S LAKE ST FOREST LAKE MN 55025- 8/02/2006 LM 4680(8/99) • • • • ` • City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(65I)439-4439 Facsimile(651)439-0574 facsimile transmittal To: LMCIT Fax: 651-281-1297 From: Gary Brunckhorst Date: 5-31-06 Re: WC Renewal Data Pages: 3 CC: ❑ Urgent ❑For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle Notes: • ..:. � *:.* League of Minnesota Cities Insurance Trial, C, n d Group Self-Insured Workers' Compensation Plar D 145 University Avenue West St. Paul, MN 55103-2044 APR 2 7 • RENEWAL DATA 1\c The "City:" OAK PARK HEIGHTS, CITY OF Agreement No. : 0200072919 PO BOX 2007 Quote To: OAK PARK HEIGHTS MN 55082 Quote Due On: 6/01/06 Agreement Expires: 7/07/06 Your coverage under the LMCIT Self-Insured Workers' Compensation program will expire soon. This Renewal Data sheet will be used to generate a premium quote for the different workers' compensation plans available. A copy of the City's previous year's selected coverages and premiums is attached for your reference. Coverage Options All of the options available to the City are outlined below, and described in the accompanying memo, Things to Think About When Renewing Your City's Workers' Compensation Coverage.You can select any coverage options in which the City may be interested. Premium quotes for all coverage options will be provided, and a final coverage decision can be made at the time you receive the complete quote. Elected Officials: Please indicate if the City would be interested in covering elected officials. Yes X No If yes, please list the estimated annual payroll for all elected officials the City would like to cover under workers' compensation. The 2006 premium rate for mayors and council members is $ .41 per$100 of payroll. This rate is applied to the greater of either the official's actual salary or an imputed salary of$70 per week. Note: Coverage for elected officials requires a resolution passed by the City Council. • Payroll Description Code Amount Elected Officials 9411 $ 26000 Members of Separate Administrative Boards:Please indicate if the City would be interested in covering members of separate administrative boards. Yes X No If yes, please select any separate administrative boards the City would like to cover under workers' compensation. (This coverage includes Board Members only.) 1. Utility or utility commission 5. Welfare or public relief agency 2. Port authority 6. School board 3. Housing and redevelopment authority 7. Joint powers board 4. Hospital or nursing home board or commission 8. X Other EDA. Parks & Planning Employees of Separate Administrative Boards:If the City has elected to cover specific Board MembersVabove e uity-) also employees hoose to cover of those boards. Please indicate which type of quote the City would like: P Y No quote for administrative board employees. Combined quote to include employees of both the administrative board and the City. Separate quote for employees of the City and each administrative board selected above. Volunteers: Please indicate if the City would be would like to cover City volunteers not designated as employees, such as coaches, instructors, event workers, "clean-up" day volunteers, etc. (Volunteer firefighters, ambulance attendants, first reponders, la rcement assistance volunteers, civil defense volunteers, and any other volunteers defined by statute as employees for pu es of work comp coverage are already covered and are not part of this election.) Yes No X (over) City Employees: Please indicate the estimated payroll for City employees for the coming policy year. The payroll descriptions and codes provided are the most commonly used. If you need to add additional payroll descriptions, please use the blank spaces and the codes on the attached list. li Sickiliday, and vacation pay should be included in the payroll totals. Do not reduce payrolls for sick, holiday, and vacation pay. Does your City have a flexible benefits plan such as a cafeteria plan, Section 125 plan, or flexible reimbursement account plan? Yes X No Employee contributions to a flexible benefits plan should be included in the payroll figures you provide. City contributions should not be included. (This is similar to how these plans are treated under PERA.) Payroll Description Code Amount Payroll Description Code Amount Ambulance Services(Not Volunteer) 7380 $ Sewage Plan 7580 $ 74356 Ambulance Services(Volunteer) 7381 $ Off Sale Liquor Store 8017 $ Building Operations 9015 $ Street and Road Construction 5506 $ 19828 City Shop and Yard 8227 $ Waterworks 7520 $ 123926 Clerical Office 8810 $ 378922 other: Mayor & Council 9411 $ 26000 Electric and Steam Power 7539 $ Other: Rink Attendants 90T6 $ 4829 Firefighters(Not Volunteer) 7706 $ Other: $ Firefighters(Volunteer) 7708 pop Other: $ Municipal Employees 9410 $ 83307 Other: $ Parks 9102 $ 22169 Other: $ Police 7720 $ 715608 Other: $ Restaurant and Bars(on sale) 9084 $ Other: $ PREMIUM OPTIONS Ple lest the premium options below in which the City is most interested. All of the premium options selected will be quoted to City; k wever, only one premium option can be ultimately assigned for the coming plan year. Regular Premium Option: Please indicate if the City would be interested in the regular premium option. Yes No X Deductible Options: Please Indicate the deductible level and associated premium discount the City would like to consider. Deductible Premium Credit $250 2.50% $500 4.00% $1,000 6.00% $2,500 10.00% $5,000 14.00% $10,000 19.50% Retrospective Rating:Please indicate if the City would be interested in retrospective rating(if applicable). Yes No X Managed Care Option: Please indicate if the City participates in a state-certified managed care organization (MCO) for workers' compensation benefits, and if so, the name of that organization. Yes No X MCO: Contact Information: Please provide us with a contact for questions about the City's workers' compensation coverage. jholst @ci.tyofoakpark City Contact Person Judy Hoist Phone 651-439-4439 Email heights . com 0 Please fax this completed form to the League of Minnesota Cities Insurance Trust at 651-281-1297. If you have any questions, please contact Barb Meyer, Policy Services Technician, by phone at 651-215-4173 or 800-925-1122, or via email at bmeyer2elmnc.org. Comp Time Prey. Yr 06' 07' Holiday Overtime 06' + 07' earings Council David Beaudet 3,000 3,000 $ 6,000 $ 6,000 Les Abrahamson 2,500 2,500 $ 5,000. $ 5,000 Jack Doer 2,500 2,500 $ 5,000 $ 5,000 cComber 2,500 2,500 $ 5,000 $ 5,000 Swenson 2,500 2,500 $ 5,000 $ 5,000 Total $ 26,000 $ 26,000 9411 Part Time Parks John Sortedahl 1,250 $ 1,250 Nick 500 $ 500 Brianna 1,250 $ 1,250 Mike Wood 239 $ 239 Mike Wilson 1,600 $ 1,600 Greg Lehmicke 2,400 $ 2,400 Jacob Schaubach 2,400 $ 2,400 Total $ 9,639 9102 $ 4,820 9016 $ 4,820 Police Stanley Buckley 32,304 33,273 3,084 1,970 $ 70,631 $ 67,635 1.04 Michael Hausken 35,559 36,626 3,626 2,133 $ 77,943 $ 76,709 1.02 Lindy Swanson 42,834 44,119 1,697 $ 88,650 $ 87,494 1.01 Kenneth Anderson 32,328 33,298 2,969 3,796 $ 72,392 $ 68,146 1.06 Paul Hoppe 35,559 36,626 3,626 194 $ 76,004 $ 74,826 1.02 Fred Kropidlowski 31,364 32,305 3,255 2,560 $ 69,483 $ 68,374 1.02 Brian DeRosier 31,723 32,675 3,358 166 $ 67,922 $ 67,545 1.01 Joseph Croft 31,076 32,008 2,627 9,528 $ 75,239 $ 73,953 1.02 David Kisch 31,076 32,008 3,388 2,748 $ 69,220 $ 68,110 1.02 Sea Kruse-Roslin 23,603 24,311 210 $ 48,124 $ 47,411 1.02 Total $715,608 7720 Office Staff Gary Brunckhorst 28,255 29,103 296 $ 57,653 $ 55,145 1.05 Judy Hoist 41,748 43,000 2,033 $ 86,782 $ 82,437 1.05 Julie Hultman 26,716 27,518 626 $ 54,860 $ 52,485 1.05 Eric Johnson 41,394 42,635 - $ 84,029 $ 86,947 0.97 Julie Johnson 22,526 23,202 866 $ 46,594 $ 44,585 1.05 Lisa Taube 24,088 24,810 106 $ 49,004 $ 46,877 1.05 Total $378,922 8810 Building Insp. Jimmy Butler 34,933 35,981 $ 70,914 $ 67,283 1.05 9410 Breakdown Public Works Jeff Kellogg 28,255 29,103 7,734 $ 65,092 $ 62,367 1.04 5506 19,828 Andrew Kegley 18,737 21,107 2,911 $ 42,756 $ 30,036 1.42 7520 123,926 Tom Ozzello 42,132 43,396 251 $ 85,779 $ 72,809 1.18 7580 74,356 Mark Robertson 24,309 25,038 4,880 $ 54,226 $ 44,350 1.22 7720 715,608 8810 378,922 Total $247,853 9102 22,169 Public Works Breakdown 9410 83,307 9102 8% ` 4S3 17, ** 9411 26,000 5506 50% 9016 4,820 • 7520 30% 123, f1 at 7580 7% i 1,448,936 9410 5% $ 1,448,936 arks W ork(ers League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 Phone (651)215-4173 Information Page 1. The "City" RENEWAL Agreement No.: 0200072919 OAK PARK HEIGHTS, CITY OF PO BOX 2007 -, ,, "City"is: x City OAK PARK HEIGHTS MN 55082 L,\f ii s;;N\i iUn _ Joint Powers Entity DO NOT DAY Other(describe) 2. The Agreement Period is from 12:01 a.m. 7/07/2005 to 12.01 a.m. 7/07/2006 at the "City's" address. 3. A. Workers' Compensation Coverage: Part One of the Agreement applies to the Workers' Compensation Law of any state of the United States of America and the District of Columbia. B. Employers Liability Coverage: Part Two of the Agreement applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury-Each Occurrence $1,000,000 Bodily Injury by Disease-Agreement Limit $1,000,000 C. Part Three of the Agreement applies to Infectious Disease Diagnostic Testing. D. Part Four of the Agreement applies to Peace Officers' Posttraumatic Stress Syndrome Benefit. E. This Agreement includes these amendments and schedules: 411 4. Retro-rating option selected? ,Yes x No 5. Elected Officials Covered? Yes Boards and Commissions Covered (List) NONE 6. The premium for this Agreement will be determined by our M4iivals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Premium Basis Rates Entries in this item, except as specifically provided Estimated Estimated Total Per$100 of Code elsewhere in this Agreement; Do not modify any of the Annual Annual Remuneration No. other provisions of the Agreement Premium Remuneration SEE ATTACHED SCHEDULE FOR DETAILS Manual Premium 37791. Experience Modification .82 6802. Standard Premium 30989. Managed Care Credit 0% Deductible Credit .0 % Agent: 411709883 570.40 Premium Discount 2469. 874 FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS Net Deposit Premium 28520. 232 S LAKE ST FOREST LAKE MN 55025- 7/01/2005 LM 4670(12/99) League of Minnesota Cities Insurance Trust Group Self-Insured Workers' Compensation Plan 145 University Avenue West St. Paul, MN 55103-2044 (651)215-4173 Olie "City" Agreement No.: 0200072919 Agreement Period From: 7/07/2005 OAK PARK HEIGHTS, CITY OF =XPPJNG INFO MAflQ l To: 7/07/2006 PO BOX 2007 OAK PARK HEIGHTS MN 55082 DO NOT PAY CONTINUATION SCHEDULE FOR INFORMATION PAGE I REMUNERATION RATE CODE DESCRIPTION EST. PREM 17422. 6.71 5506 STREET CONSTRUCTION 1169. 108889. 2.89 7520 WATERWORKS 3147. 65334. 3.84 7580 SEWAGE DISPOSAL PLANT 2509. 703877. 3.86 7720 POLICE 27170. 367466. .58 8810 CLERICAL OFFICE EMPLOYEES NOC 2131. 4865. 2.42 9016 SKATING RINK OPERATION 118. 20109. 3.06 9102 PARKS 615. 79101. 1.05 9410 MUNICIPAL EMPLOYEES 831. 26000. .39 9411 ELECTED OR APPOINTED OFFICIALS 101. Manual Premium 37791. • Agent: 411709883 00874 : FOREST LAKE INSURANCE AGENCY DBA LANDMARK INSURANCE SVCS 232 S LAKE ST • FOREST LAKE MN 55025- . 7/01/2005 LM 4680(8/99) League of Minnesota Cities Insurance Trust 145 University Avenue West,St Paul,MN 55103-2044 Cities (651)281-1200 • (800)925-1122 41, Laagaw of Minnarota Cain i ng Fax:(651)281-1298 •TDD:(651)281-1290 www.Imnc.org MINNESOTA WORKERS' COMPENSATION NOTICE OF RENEWAL This information is provided to assist you in understanding your workers' compensation coverage and renewal options. Please read all the information carefully before making selections for the next coverage period. The following information is included: • Renewal Data Form • Copy of previous year's coverage selection and premium information page • Risk management memorandum: Things to Think About When Renewing Your City's Workers' Compensation Coverage If you have additional questions about the coverage options available to your City,please contact the League of Minnesota Cities Insurance Trust: Barb Meyer, Policy Services Technician Jan Kodet,Underwriting Supervisor • Phone: 651-215-4173 Phone: 651-215-4082 Fax: 651-281-1297 Fax: 651-281-1298 Email: bmever2 @lmnc.org Email: jkodet @lmnc.org Deb Anger, Claims Manager Bill Everett,Associate Administrator Phone: 651-215-4170 Phone: 651-281-1216 Fax: 651-281-1297 Fax: 651-281-1298 Email: dangerlmnc.org Email: beverett@lmnc.org Any of the above listed individuals can also be reached at 800-925-1122 41) AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER 11---‘'7'1 LMC League of Minnesota Cities Insurance Trust 145 University Avenue West,St Paul,MN 55103-2044 • (800)925-1122 • (651)281-1200 (8 Oy '`°e"°Of`H'""QdO& ' Fax:(651)281-1298 • TDD:(651)281-1290 Cities promoting woa�ttarcQ www.lmnc.org May 4,2005 To: LMCIT member cities and agents-cities using CMC managed care From: Pete Tritz Re: Cancellation of CMC contracts We were informed this week that Comprehensive Managed Care (CMC),which is Blue Cross's workers compensation managed care facility, will cease operations effective June 30,and that all existing CMC managed care contracts will be cancelled as of that date. LMCIT for many years has offered a 3%credit on work comp premiums for cities that enroll with a certified managed care provider, and over 200 LMCIT member cities have enrolled with CMC for work comp managed care. In this memo we'll try to answer your questions about how this decision by CMC will affect your city's coverage with LMCIT. • What do cities with CMC contracts need to do? You need to immediately remove any posters or other materials you have that direct employees to CMC's provider network for treating work-related injuries. Of course, employees are certainly free to continue to obtain care from those providers if they choose. You will also need to decide whether you wish to enroll with another certified managed care organization(MCO). There are now three remaining certified managed care providers in Minnesota: Corvel, which currently serves 46 LMCIT member cities; HealthPartners, which serves two LMCIT member cities; and Intercorp/Araz,which currently doesn't serve any LMCIT member cities. Some factors to look at in selecting an MCO are whether the MCO has network providers in your area; the MCO's fees and charges; and whether the MCO's overall approach and philosophy matches the city's. Additional information on work comp managed care is available on the Department of Labor and Industry website at http://www.doli.state.mn.us/faq managedcare.html. Contact information for the three remaining certified managed care organizations is attached. If your city is considering or planning to enroll with another certified managed care provider, please let the LMCIT work comp claims staff know right away. Unless and until we hear from the city,we'll assume that no managed care plan is in place for the city. AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER How is LMCIT handling claims for CMC cities? • Effective immediately, LMCIT has stopped reporting any new claims to CMC. Even though the CMC contracts arguably may technically still be in effect,the indications are that CMC likely won't do much if anything on new claims that come in. There therefore seems little point in continuing to incur CMC's$25 per claim filing charge for the next couple months. How will the premium credit be affected for cities whose CMC contracts are cancelled? LMCIT will not make any mid-term premium adjustments for cities whose CMC contracts terminate mid-term, even if the city does not enroll with another certified managed care organization. In other words, if you have LMCIT coverage currently in place and have received the 3%premium credit on that coverage for having CMC managed care, you won't get another bill from LMCIT for a pro rata portion of that 3% credit, regardless of whether or not you've enrolled with another managed care organization. Of course, you will not receive the 3%credit on your next renewal unless you've enrolled with another managed care organization. We're just in the process of renewing our LMCIT work comp coverage. How does the termination of CMC affect us? May 4 is the cut-off date. After that, cities can no longer use CMC to qualify for the 3% managed care premium credit. In other words: • If your city's renewal date was May 4 or earlier and you signed and returned the option form • indicating that you have managed care coverage with CMC, you will receive the 3% premium credit for this coverage year. • If your renewal date was May 4 or earlier but you haven't yet signed and returned the premium option form, you will not receive the 3%premium credit for CMC enrollment. You can, of course,receive the credit if you enroll with another MCO. • If your renewal date is after May 4, you will not receive the 3% managed care premium credit unless you enroll with a managed care organization other than CMC. If you have questions,please contact either of the following: • Deb Anger, LMCIT work comp claims manager 651-215-4170 or danger @lmnc.org • Pete Tritz, LMCIT Administrator 651-281-1265 or ptritz @lmnc.org • Certified workers compensation managed care organizations • CorVel (612)436-2500; 1-800-275-8893 Contact: Employee Intake Nurse 3001 N.E. Broadway Street Suite 600 Minneapolis, MN 55413 Fax: (612)436-2499 HealthPartners (952)883-5484; 1-888-544-5484 Contact: Care Line 8100 34th Ave. S. P.O. Box 1309 Minneapolis,MN 55440 Fax: (952) 883-5210 Intracorp/Araz 1-800-803-0344,ext. 2145 Contact: Audrey Schlong 11095 Viking Drive Suite 520 Eden Prairie, MN 55344 Fax: (952) 996-2159 • A League of Minnesota Cities Insurance Trust LMC 145 University Avenue West,St.Paul,MN 55103-2044 League of Minnesota Cities (651)281-1200 • (800)925-1122 C,tiea promoting examen Fax:(651)281-1298 • TDD:(651)281-1290 J www.lmnc.org RISK MANAGEMENT INFORMATION THINGS TO THINK ABOUT WHEN RENEWING YOUR CITY'S WORKERS' COMPENSATION COVERAGE The LMCIT workers' compensation program is specially designed for Minnesota cities. LMCIT's coverage is unique because it picks up some related risks that standard workers' compensation insurance policies don't cover. This program also offers a number of coverage and premium options, deductibles and credits. LMCIT tries to make buying coverage for the city's workers' compensation exposures as simple and straightforward as possible,but there are still a number of decisions the city needs to make in renewing its work comp coverage. This memo is intended to serve as a guide for cities and agents when thinking about purchasing or renewing work comp coverage. Boards and commissions Elected officials • Unlike city employees, elected officials are not automatically covered by the work comp law. Cities wishing to cover elected officials need to pass an ordinance or resolution to make the elected officials "employees"for purposes of work comp coverage. If the city does not pass the resolution, a city official that is injured while on city business wouldn't receive any work comp benefits from the city. This mostly affects mayors and council members,but it could also apply to clerk, treasurers, and other officers in cities where those are elected positions. The 2006 premium rate for mayors and council members is $.41 per $100 of payroll. This rate is applied to the greater of either the official's actual salary or an imputed salary of$70 per week. In case of injury, an elected official would receive the same work comp benefits as any other city employee. Indemnity benefits would be based on the sum of his/her earnings from his/her regular employment plus the actual salary(if any) s/he receives from the city. An alternative to work comp coverage for elected officials is to purchase LMCIT's board member accident coverage. Under this option, cities can provide more limited benefits to council members injured or killed in the course of performing their duties. Accident policy rates are $12.75 per person per year. Benefits are paid for death or short-term disability. This program was originally developed a number of years ago as a low-cost alternative to work comp for elected officials. However, LMCIT has reduced the cost of work comp for elected officials very substantially since then, so the cost advantage of the accident coverage option is now minimal. S Here's a summary comparison of the two ways cities can cover elected officials through LMCIT: • LMCIT elected officials work LMCIT elected officials accident comp coverage coverage Premium cost $.40 per$100 of actual payroll or $12.75 per person per year imputed salary Coverage benefits • Death • Death • Short-term disability • Permanent impairment • Loss of wages • Short-term disability • Rehabilitation • Medical expenses • Permanent disability For more information about coverage for elected officials,refer to the"Coverage for Injuries to Elected and Appointed Officials"memo. Members of separate administrative boards Members of administrative boards that the city creates pursuant to statute or charter can also be covered by workers' compensation in the same way as elected officials if the city passes the appropriate ordinance or resolution. Common examples of these types of boards include planning commissions, housing and redevelopment authorities,port authority boards,EDA boards, utilities commissions,park boards, and hospital or nursing home boards. The accident coverage alternative is also available for these positions. For more information about coverage for members of separate boards, refer to the "Coordinating Coverages for Separate City Boards and Commissions"memo. Employees of separate administrative boards In some cases, the city may prefer that entities which are managed by a separate administrative board have their own work comp coverage separate from the city. HRAs, EDAs,port authorities, utilities commissions, and hospital or nursing home boards are examples. Alternately,these employees can be included under the city's general coverage. Having separate coverage may make it easier to allocate costs appropriately between the two budgets. Another reason cities sometimes choose to use separate coverage is so each operation stands on its own for purposes of the experience modification calculation. I.e., with separate coverage, the utilities commission's employees losses won't affect the city's experience modification, and vice versa. On the other hand,by separating the two,the city may lose some benefit of the volume discount on premiums. -2- LMCIT can provide the coverage either way,but the important thing is to make sure that all • parties involved are clear on what the intent is. Note that employees of an utilities commission, HRA, EDA, port authority, or hospital or nursing home board are not automatically covered by the city's LMCIT work comp coverage unless that board is specifically listed on the information page of the coverage document. Joint powers boards If a joint powers board has its own employees, it needs work comp coverage. Any joint powers board which has at least one city as a member is eligible for LMCIT work comp coverage. LMCIT can provide that coverage either by issuing separate coverage to the joint powers board, or by adding the joint powers board as a covered employer on the city's LMCIT work comp coverage. Advisory boards Unpaid members of advisory boards that do not have legal decision-making authority are not eligible to be covered by work comp. However, cities may obtain board accident coverage from LMCIT for members of advisory boards at the same rate as for administrative boards. Volunteers Volunteers considered employees • Certain volunteers are defined by statute as employees for purposes of work comp coverage. These include volunteer firefighters, ambulance attendants, first responders, law enforcement assistance volunteers, and civil defense volunteers. These volunteers are entitled to receive work comp benefits if they are injured while performing volunteer services for the city, and are covered under the city's regular work comp policy. Volunteers in an emergency City volunteers at work during an emergency are entitled by statute to work comp benefits under a city's policy. Emergency city volunteers must be registered with the city and work under the direction and control of the city. LMCIT does not charge any additional premium for this work comp exposure. (Like other city volunteers, emergency volunteers are also automatically "covered parties" under the city's LMCIT liability coverage.) For more information,refer to the "Providing Assistance in Emergencies: Coverage and Liability Issues" memo. Other city volunteers Other city volunteers are not considered employees and are therefore not covered by workers' compensation. For these volunteers, LMCIT offers an optional volunteer accident coverage, which provides some limited"no-fault"benefits for volunteers injured while working for the city. Volunteers under this program receive limited death, disability and impairment benefits. The city can also add coverage for up to $1,000 of medical costs for an additional charge. This • -3 - coverage could help avoid litigation in cases where the city may be at fault, and it also provides some protection for people donating their time and effort to city projects. Volunteer accident coverage provides blanket coverage for all city volunteers working under city direction and control, such as coaches and instructors in recreation programs, or volunteers working on city-sponsored festivals or celebrations. The cost of volunteer work comp coverage is based on the city's population,with a basic annual charge of$.10 per capita subject to a minimum premium of$150 and a maximum premium of$1,500 annually. The charge to add volunteers working on a construction project is $300 per project. For more information, refer to the"Accident Coverage for City Volunteers"memo and the "Covering the City's Volunteers"memo. Premium options LMCIT work comp members have a number of premium options as well as an option to close- out retro coverage from previous years. Members also have the option of using a managed care provider for the medical management of employees injured while at work. Regular premium Under the regular premium option,the City's premium is calculated based on City payroll, by class. The premium is then adjusted by an experience modification factor, which reflects the AK City's previous loss experience. In the experience modification process, claims in the oldest three out of the past four years are considered. In other words,the most recent past year is not considered. If a city chooses the regular premium option,premium payments are the City's only responsibility or liability. The regular premium option is a"fully insured" option for the City to elect. Retrospective rating Under LMCIT's retro-rating plan, a city's final premium costs reflects its own, actual loss experience for the year. Cities with standard premiums of$25,000 or more can if they wish select one of three retrospective options, so that each city may select the amount of risk it wishes to retain. Retrospective rating is a form of risk retention. The final premium under a retro is a function of the city's own losses, so a good safety program is important if you're using a retro. With good loss experience, a retro can save the city significant money over the long run. Of course the city is also subject to possible premium increases if it experiences a lot of injuries or a single big loss. Cities that select a retrospective rating option pay a deposit premium to LMCIT at the beginning of the agreement period. Six months after the end of the agreement year,the city's premiums are adjusted up or down based on the city's actual incurred losses for that year. That adjustment is repeated annually until all claims from the agreement period are closed. • -4- A Before selecting retro-rating, it's often helpful to do a"what if' calculation of what the city's premiums would have been for each of the past few years if the city had had a retrospective rating plan in place. This can be a useful tool for cities evaluating retro-rating options. A city that's using a retro option should annually review that decision to make sure it still makes sense for the city. A good time for that review is when you receive the annual adjustment bill or refund, about six months after the city's expiration date. The adjustment mailing includes the relevant loss and premium data, so you'll have the information you need and plenty of time to review and make an informed decision for the upcoming renewal. Especially in your first year under a retro, it's a good idea also to look at your current-year losses after nine or ten months to see how you're doing and whether you want to continue with the retro at your renewal. A couple questions to ask when reviewing the retro option: • Are the funds available to cover the city's potential costs? Remember that even a single serious injury could be expensive enough to push the city's cost to the maximum for the year. Keep in mind too that claims from prior years sometimes re-open or increase in cost, which means that the city can owe addition amounts for prior years as well. To use a retro is to retain risk, and when you retain risk it's critically important that that risk be funded—i.e., have a plan for where the funds would come from to cover the city's potential obligations under the retro. • Does the retro-rating option still make sense for the city? Are you still comfortable trading off certainty in costs for some potential savings? In light of your loss history and your safety program, are you reasonably confident that you'll be able to keep employee injuries down enough to save money in the coming year? For more information about the retrospective rating options, refer to the "Workers' Compensation Retrospective Rating Options" memo. Retro close-out option After five years, the city has the option to close out retro-rated coverage from previous years. If a city closes out the retro, no further adjustments are then made to the city's premiums under the retro-rated formula,regardless of what future changes there may be in the city's paid or incurred losses. The charge for the close-out is a percentage of the city's incurred losses for the coverage year in question. You may call Barb Meyer at 651-215-4173 to calculate your city's close-out charges. For more information about the retro close-out option, refer to the"Workers' Compensation Retro Close-Out Option"memo. Deductible options Under a deductible option,the city pays a lower premium in return for agreeing to reimburse LMCIT for paid medical losses up to a set deductible. If the city selects a deductible option,the deductible applies per occurrence to medical costs only. There are six deductible options ranging from a$250 deductible with a 2.5%premium credit to a$10,000 deductible with an 19.5%premium credit. 1111 - 5 - M Deductibles do not affect the experience modification calculation. Even though under a • deductible option the city reimburses LMCIT for certain medical costs,those costs are still included in calculating the experience modification. Like the retro-rating options, deductibles are a way of retaining risk, so if the city uses a deductible option it's important to fund that risk. Remember that the deductibles apply per occurrence, and you need to be prepared for the possibility that you'll have multiple occurrences during the year. For more information on deductible options, refer to the"Workers' Compensation Deductible Options"memo. Managed care option Cities that enroll with a state-certified managed care organization(MCO)receive a 3%premium credit on their work comp coverage. MCOs attempt to reduce the total costs of work comp claims by providing care in a network setting, establishing cost effective treatment protocols, and working to return the employee to work as soon as possible. If the MCO is successful in reducing loss costs, the city would see additional savings in the form of an improved experience modification. LMCIT has been monitoring cities' experience with MCOs for several years. The results are not clear-cut, though the most recent review suggests that managed care may be producing at least some overall savings for some cities. There are now only three certified MCOs in Minnesota: Corvel, which is the one that cities have used most often; HealthPartners, which several cities use; and Intracorp/Araz. Some factors to look at in selecting an MCO are whether the MCO has network providers in their area; the MCO's fees and charges; and whether the MCO's overall approach and philosophy matches the city's. For a current list and contact information for certified MCOs, contact the Department of Labor and Industry at 800-342-5354 or www.doli.state.mn.us. Non-smoker credit for police and firefighters LMCIT offers member cities a 10 percent rate credit for non-smoking police and firefighters. To qualify for the credit,the city must obtain written statements of non-smoking from at least 90 percent of the members of the department. The statement must be signed and dated, and must state that the individual does not smoke and has not smoked within the previous six months. LMCIT gives this discount because several of the diseases presumed by statute to be job-related for firefighters and police officers—various heart diseases, lung diseases, and cancers—are also related to smoking. Fire or police departments with very few smokers represent a lower risk for claims for heart disease, lung disease, or cancer. For more information on how this credit works, refer to the "Workers' Compensation for Volunteer Firefighters"memo. PST 01/06 -6- L N 145 University Avenue West, St. Paul, MN 55103-2044 Phone: (651) 281-1200 • (800) 925-1122 TDD (651) 281-1290 League of Minnesota Cities LMC Fax: (651) 281-1299 • LMCIT Fax: (651) 281-1298 Cities promoting exceence I ll Web Site: http:iiwww.lmnc.org March 2002 To: LMCIT Workers'Compensation member cities Re: Certification of non-smoking status for police and fire department members The League of Minnesota Cities Insurance Trust(LMCIT)allows cities a 10 percent reduction in the premium charged for workers' compensation coverage for police and fire departments,if the city can certify that at least 90 percent of the department's members are non-smokers. To certify non-smoking status,cities must ask police and fire department staff to fill out a form indicating that they do not smoke. This information is private employee data. LMCIT recommends that police and fire department members be provided with appropriate information about the request when it is made of them(Tennessen warning). It is the city's responsibility to provide appropriate information about why this private data is being requested from the employee,and also to maintain the information correctly. To help you with this process,LMCIT is providing a sample non-smoking certification that includes a Tennessen warning to the employee. This sample document is on the back of this page,and can be copied for city use. LMCIT will also accept other certification that the city might choose to submit from police or fire department staff. Please keep in mind the need to provide employees with information about why the request is being made,what the data will be used for,and who will have access to the data submitted. If you have any questions,please contact LMCIT at 651-281-1200 or 800-925-1122. • AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER ' I- -' Notice to Police and Fire Department Members • City of Fire Department or Police Department The League of Minnesota Cities Insurance Trust(LMCIT)allows cities a 10 percent reduction in workers' compensation premium for police and fire departments, if the city can certify that at least 90 percent of department members are non-smokers. The information below is requested in order for your city to receive this discount. The information will be submitted by the city to LMCIT,where it will be used to determine premium discount status.You are not required to provide this information at this time. If you refuse to supply the information,you will face no disciplinary action as a result of the refusal. However, • If you provide false or misleading information, it may be used by the city to impose discipline against you,including dismissal;and • At some point in the future,the city may choose to require you to provide this information. At that time,you will be provided another advisory telling you of the requirement and the consequences for refusing. Other persons or entities who are authorized by law to receive this information are: employees,agents,and officials of the city who have need to know about the information in the course of their duties or • responsibilities,the person who is the subject of the data about him or herself,people who have permission from the subject of the data,and LMCIT. If it is reasonably necessary to discuss the information at a city council or board meeting,it will be available to members of the public. Advisory provided to by (employee) (city contact) on at (date) (time) EMPLOYEE COMPLETES THIS PORTION: I acknowledge receiving this advisory. I do not smoke and have not smoked within the past six months. (signature) (date) •