Department of Labor and Industries Self-Insurance PO Box 44891 Olympia WA 98504-4891 ACKNOWLEDGEMENT OF SECURITY INTEREST Name of Deposit Bank Address City State ZIP+4 Name of Self-Insurer UBI Number / Account ID The above named parties acknowledge that the funds deposited into account _______________________________ at Number the bank are solely for the purpose of providing for thye menpat of workers compensation benefits and assessments in the event of default by the self-insurer. Deposit bank agrees to the following: 1. The account instrument will be registered in the name of ____________________________________________as escrow agent for the self-insurer. Escrow Bank Name 2. The account instrument will be held in escrow byescrow the bank until release is authorized in writing by the Department of Labor and Industries. 3. Notice of maturity of the account instrument will be sent to both the self-insurer and the escrow bank. 4. In the event of a default by the self-insurer on its obligation under Title 51 RCW, title to the funds deposited herein automatically passes to the Department of Labor and Industries. 5. In the event of a bankruptcy proceeding entered in thto e self-inbysurer or initiated b iyts creditors, where the self-insurer defaults on its obligation under Title 51 RCW, the my doneeposited herein is not the property of the estate of the debtor. Regardless of whether the bankruptcy proceeding is instituted before or after the default occurs, title to the money deposited herein passes automatically to the Department of Labor and Industries upon default without requiring court approval. Signature of Deposit Bank Representative Signature of Self-Insurer Representative Title of Deposit Bank Representative Title of Self-Insurer Representative Date of Acknowledgment American LegalNet, Inc.F207-143-000 security interest 8-96 www.USCourtForms.com