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