Les Form Si-32 - Assignment Of Securities Form printable pdf download

SAMPLE (Held by Bank or Savings & Loan)

ASSIGNMENT OF SECURITIES

Agreement made this _______________ day of _______________, 19 ____________ between (name of self-insurer)

and the Director of Workers' Compensation, Department of Labor and Employment Security, 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, Department of Labor & Employment Security, 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, Department of Labor & Employment Security 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,

Department of Labor & Employment Security, 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 Operations Support

Self-insurance Section

For the Director of Workers' Compensation

Department of Labor & Employment Security

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)

(telephone number)

LES Form SI-32 (09/96)

Les Form Si-32 - Assignment Of Securities Form