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Key Risk Insurance Company
<br />0
<br />7900 McCloud
<br />Road, Suite 300
<br />Greensboro, NC 27409
<br />Application for
<br />Consent To Rate
<br />Insured: Lee County Government
<br />Agent: Millennium Insurance Group
<br />Address: 106 Hillcrest Drive
<br />Address: PO Box 2005
<br />Sanford, NC 27330
<br />Thomasville, NC 27361
<br />Policy Number: 950-94
<br />Effective Date July 1, 2010
<br />Line of Business: Workers Compensation
<br />Policy Term
<br />July 1, 2010-2011
<br />Employers Liability Limits 1,00011,000/1,000
<br />Class Code Payroll Filed Rate Premium Proposed Rate
<br />Premium
<br />%Increase
<br />7380 325,182
<br />636
<br />20,682 9.35
<br />30,405
<br />47.013%
<br />7720 2,886,953
<br />3.73
<br />107,683 5.48
<br />158.205
<br />46.917%
<br />8810 5,204,652
<br />0.33
<br />17,175 0.49
<br />25,503
<br />48.488%
<br />8820 155,763
<br />028
<br />436 0.41
<br />639
<br />46.475%
<br />8831 60,019
<br />1.89
<br />1,134 2.78
<br />1,669
<br />47.1370/.
<br />8832 795,539
<br />0.50
<br />3,978 0.74
<br />5,887
<br />47.989%
<br />8835 422,625
<br />3.85
<br />16,271 5.66
<br />23,921
<br />47.014%
<br />9015 945,658
<br />3.71
<br />35,084 5.45
<br />51,538
<br />46.900%
<br />9101 21,608
<br />4.43
<br />957 6.51
<br />1,407
<br />46.989%
<br />9102 519,485
<br />3.89
<br />20,208 5.72
<br />29,715
<br />47.043%
<br />9403 159,619
<br />11.97
<br />19,106 17.60
<br />28,093
<br />47.034%
<br />S
<br />9410 3,191,517
<br />2.85
<br />90.958 4.19
<br />133,725
<br />47.018%
<br />9410V 34917
<br />2.85
<br />938 4.19
<br />1.379
<br />47.038%
<br />Manual Premium
<br />334,610
<br />492,083
<br />Increase Limit
<br />2.8%
<br />9,369 2.8%
<br />13,778
<br />Deductible Credit
<br />Experience Mod
<br />0.92
<br />-27,518 0.92
<br />40,466
<br />Drug Free Credit
<br />Standard premium
<br />316,461
<br />465,395
<br />Premium Discount
<br />11.89%
<br />-37,629 12.12%
<br />-56,395
<br />Normal Premium
<br />278,832
<br />409,000
<br />46.683%
<br />Expense Constant
<br />275
<br />275
<br />Terror Risk Act
<br />1,472
<br />1,472
<br />Domestic Terrorism Charge
<br />1,472
<br />1,472
<br />Total
<br />282,051 Premium
<br />412 919
<br />Is the proposed rule greater than 250% of Filed Rates? No X
<br />_ Yes (see attached explanation)
<br />Any proposed rate in excess of 250 percent must be explained
<br />fully and shall be subject to review and approval of the
<br />Commissioner pursuant to G.B. 58-36-30(b).
<br />Key Risk Representative
<br />Dale
<br />I understand that comparable coverage is ava
<br />ilable through the North Carolina Workers Co
<br />mpensation Insurance Plan and
<br />agree to accept the Proposed Rates and Prem
<br />ium.
<br />Accepted By:
<br />•
<br />Insured (Officer)
<br />Dote
<br />KRIC CTR 1 (Ed. 02101/01)
<br />
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