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Securities Deposit Agreement For Third Party Administrator Form. This is a New Hampshire form and can be use in Self-Insurance Workers Comp.
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Tags: Securities Deposit Agreement For Third Party Administrator, WCI-3, New Hampshire Workers Comp, Self-Insurance
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
Index No.
Calendar No.
SECURITIES DEPOSIT AGREEMENT
:
JUDICIAL
Plaintiff(s)
FOR THIRD PARTY ADMINISTRATOR
-against-
SUBPOENA
:
:
KNOW ALL MEN BY THESE PRESENTS:
:
That we,
Defendant(s)
:
. . . . . as. Principal, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . and
as Fiduciary, are holden and stand firmly bound and obliged unto the State of New Hampshire in the full
and just sum of _______________________________Dollars ($______________________) which is, at
present, the aggregate market value of the securities on deposit with the Fiduciary, to the true payment
whereof we bind ourselves, our heirs, administrators, executors, successors, and assigns, jointly and
THE PEOPLE OF THE STATE OF NEW YORK
severally.
TO WHEREAS the Labor Commissioner agrees to discharge his duties and responsibilities with respect to the
said deposit of securities in accordance with the said statute, all rules and regulations promulgated
thereunder, the provisions of this agreement, and his commission.
NOW THEREFORE, the condition of this agreement is such that it shall remain in full force and effect
GREETINGS:
until other guarantees have been substituted by the Principal in amounts to be approved by the
Commissioner, except if the principal ceases to be Third Party Administrator subject to Chapter 161, except
as toWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
such liability which has accrued during the life of this agreement.
,
the Honorable
at the
Court
County is understood and agreed thatlocated at guarantees payment of workers’ compensation benefits in
of
It
the Fiduciary
amounts, manner, and when due asof
rules and regulationsnoon, and at any recessed
promulgated
in room
, on the
day provided by the20 statute and the o'clock in the
, said , at
thereunder and that the liability of the Fiduciary a witness in this action on the part ofPrincipal within
by virtue of this agreement is that of the the
or adjourned date, to testify and give evidence as
the existing monetary value of the said deposit, and that upon default of the Principal the Fiduciary shall,
upon demand of the said Commissioner, dispose and deposit of securities in sums to be determined by him
and from the proceeds made disbursements as he shall prescribe, such sums and, otherwise, the entire
deposit being unassignable, unattachablesubpoena is punishable as athe debt of the Principal other than you liable to
Your failure to comply with this and not liable in any way for contempt of court and will make
that on whose behalf said statute.
the party incurred under the this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
It is agreed and understood that the said securities may not be withdrawn by anyone, except at the peril of
the Fiduciary, without prior written authorization of the said Commissioner. Securities may be substituted
or added by endorsement to this agreement.
Witness, Honorable
, one of the Justices of the
Court in
County,
day of
, 20
It is further agreed that the name of the account under this agreement shall be
_______________________________________/State of New Hampshire’s Workers’ Compensation Third
(Name of Third Party Administrator)
Party Administrator Program.
(Attorney must sign above and type name below)
(WCTPA 11/16/95)
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
Index No.
Calendar No.
:
JUDICIAL at the peril of
Plaintiff(s)
It is agreed and understood that the said securities may not be withdrawn by anyone, exceptSUBPOENA
the Fiduciary, without prior written authorization of the said Commissioner. Securities may be substituted
-against:
or added by endorsement to this agreement.
:
It is further agreed that the name of the account under this agreement shall be
________________________/ State of New Hampshire’s Worker's Compensation Self-Insurance Program.
:
Name of Self-Insurer
Defendant(s)
:
. . . . . This .agreement .shall .be .effective . . .the date.of .execution. by .the. last signatory.
. . . . . . . . . . . . . . . . . . . . on . . . . . . . . . . . . . . . . .
Notarization (each signature):
____________________________
Principal (Self-Insurer)
THE PEOPLE OF THE STATE OF NEW YORK
____________________________
Date
TO
____________________________
Fiduciary
GREETINGS:
____________________________
Date
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
____________________________ Court
located at Labor Commissioner
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
____________________________
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Date
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
Attorney(s) for
Office and P.O. Address
WCI-3 (1/92)
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com