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Assignment Of Securities (Sample And Form) Form. This is a Florida form and can be use in Workers Comp.
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Tags: Assignment Of Securities (Sample And Form), SI-32, Florida Workers Comp,
SAMPLE (Held by Bank or Savings & Loan)
ASSIGNMENT OF SECURITIES
Agreement made this
day of
, 20
between
(name of
self-insurer) and the Director of Workers' Compensation, State of Florida.
WHEREBY, (name of self-insured) hereby assigns (amount of security
deposit) ($
), evidenced by (type of securities) in the sum of
(amount of securities) ($
) on deposit with the (name of bank or
savings & loan) to the Director of Workers' Compensation, State of Florida, as
security deposit for (name of self-insurer) under the provisions of
440.38(1)(b), Florida Statutes.
This ASSIGNMENT is to secure the payment of those benefits provided by
Chapter 440, Florida Statutes, to the employees of (name of self-insurer).
The assigned securities shall be promptly released to the Division of Workers'
Compensation, upon certification by the Director of the Division of Workers'
Compensation that (name of self-insurer) has ceased to make the payment of
benefits required by Chapter 440.
The Division may direct that payment be
made to the Florida Self-Insurers Guaranty Association, Inc. or to the
Division of Workers' Compensation.
This ASSIGNMENT shall be a continuing one, recorded at the (name of
bank) where the security will be held for safekeeping, not to be released
without written consent of the Office of the Director of Workers'
Compensation, State of Florida.
The self-insurer shall notify the Self-Insurance Section at least three
(3) working days prior to filing for protection under the United States
Bankruptcy Code.
WITNESSED BY:
ASSIGNED BY:
(SIGNATURE OF WITNESS)
(SIGNATURE OF OFFICER OR SELF-INSURER)
(name of self-insured company)
(name of officer & title)
ACCEPTED BY:
Bureau of Monitoring and Audit,
Self-Insurance Section
For the Director of Workers' Compensation,
TITLE
The above assignment has been properly recorded on our Bank's Copy.
(signature of bank officer)
(name of bank officer & title)
(name & address of bank)
(phone no.)
Form SI-32 (9/96)
American LegalNet, Inc.
www.FormsWorkflow.com
_______________________________________
ASSIGNMENT OF SECURITIES
Agreement made this
day of
, 20
between ___
and the Director of Workers' Compensation, State of Florida.
WHEREBY,
($
hereby assigns
in the sum of
), evidenced by
($
) on deposit with the ____________________
_________________ to the Director of Workers' Compensation, State of Florida, as
security deposit for ___________________________________ under the provisions of
440.38(1)(b), Florida Statutes.
This ASSIGNMENT is to secure the payment of those benefits
Chapter 440, Florida Statutes, to the employees of
The assigned securities shall be promptly released to the Division
Compensation, upon certification by the Director of the Division
has ceased to make the
Compensation that
benefits required by Chapter 440.
The Division may direct that
made to the Florida Self-Insurers Guaranty Association, Inc.
Division of Workers' Compensation.
provided by
.
of Workers'
of Workers'
payment of
payment be
or to the
This ASSIGNMENT shall be a continuing one, recorded at the ______________
___________________________ where the security will be held for safekeeping, not
to be released without written consent of the Office of the Director of Workers'
Compensation, State of Florida.
The self-insurer shall notify the Self-Insurance Section at least three
(3) working days prior to filing for protection under the United States
Bankruptcy Code.
WITNESSED BY:
ASSIGNED BY:
ACCEPTED BY:
Bureau of Monitoring and Audit,
Self-Insurance Section
For the Director of Workers' Compensation,
TITLE
The above assignment has been properly recorded on our Bank's Copy.
Form SI-32 (9/96)
American LegalNet, Inc.
www.FormsWorkflow.com
