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O APPLICATION FOR <br /> RETROSPECTIVE <br /> RATING PLAN <br /> <br />Instruction.: <br />· Am~k~ mu~ be ~ by.~ OW~EFU~A~E~/OFmCaR. Incomplete Applications <br />· A~~~m~~. Will Be Rejected <br /> <br />~.~t.o.* ~-60016~ ~* PE Z80650~00-8 <br /> <br /> 2650 Detroit Avenue <br />Lakewood OhS~& ~'" c~'44107 <br /> <br />RETROSPECTIVE P. ATING Pl..AN PARAMETER SELECTIONS: The following retrospective rating plan paramelers <br />must be selected by the employer. The minimum and maximum premium level, as well as the exposure lo claims losses <br />will be delermined by the sets°lions made. ('.hqosa One Claim Limit and One Maximum Premium Per°anlace LlmJt <br />from the foilowln~l Tier I Parameters'. <br /> <br /> TIER I PARAMETERS <br /> Claim IJmit t35100,000 ~$125,000 E]$250.000 ~1$300,000 ~ no claim limit <br /> (maximum costs chargeable to a single claim) <br /> <br /> MAXIMUM PREMIUM % I-It50% ~200% <br /> <br />FINANCIAl. STATEMENTS ATTACHED FOR TISR 1 CONSIDERATION [:] <br /> <br /> TIER II PARAMETERS <br /> <br /> Il' you do not meet the requirements for Tier I do you want to be considered for the Tier I! plan~ [:] Yes [:] No <br /> Ir so, to enroll In the Tier I! plan choose one of the following claim limits E]$100,000 ~$125,000, <br /> only a Maximum Premium o[ 150% Is off'amd within the Tier II plan. <br /> <br /> FINANCIAl. STATEMENTS ATTACHED FOR TIER II CONSIDERATION <br /> ESTIMATED POLJCY YEAE PAYROLL- Estimated payroll to be reportsd during [he policy year must be provided for <br /> each manual classification esslgned to yom' policy number (attach additional pages as needed). The prtvale employer <br /> policy year Is July 1 to June 30 and the publl~ employ'er taxin~l dlstrlct policy year IS January I to December 31. <br /> <br /> PAYROLL ROUNDED TO THE NEAREST THOUSAND DOLLARS <br /> NCCI PAYROLL NCCl PAYROLL NCCI PAYROLL <br /> <br /> 943~ 23,644,743.03 <br /> <br />OWNER/PARTNER/OFFICER Statement of Agreement: I have read the retrospective rating roles In their entirety. <br />understand the roles and agree to cornl~ with the terms of the retrospective rating plan. <br /> T~ ~ Pflnl: O~a~er/Pa[inaflOlllc~ Name . Title. . <br />[ Yvette FI. Ittu IDlrector of Finance <br />Slonalum Oate <br /> <br />No'rE: ~--~.~o~ must ~=. re~d ~nd ..pr~,,d ~,~, .l~< T~nn,¢el Se~.e~ ee~ore it ~*;~ em,°ti e: <br /> of appll~/tlon acceptance/rejection and ,ppllcable minimum premium percentage will be mede ~ollowing the review. <br /> SVVC.OS2~ (~SV. ~97) FOR THE POLICY YEAR EFFECTIVE _ <br /> AC-20 <br /> <br /> <br />