Form E126 - Notice Of Trust Deposit Release July 2000
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1Department of Insurance
State of Arizona
Financial Affairs Division
2910 NORTH 44TH STREET, SUITE 210
Phoenix, Arizona 85018-7256
Trust Deposit Unit: (602) 912-8427
Telecopier: (602) 912-8421
NOTICE OF TRUST DEPOSIT RELEASE
PLEASE APPROVE RELEASE OF THE FOLLOWING SECURITY FROM THE ACCOUNT OF THE
ARIZONA STATE TREASURER ON BEHALF OF THE DIRECTOR OF INSURANCE, WHO IS, IN
TURN, HOLDING THE SECURITY FOR:
(Complete Name of Company)
(NAIC#)
Name of Issuer/Description of Security ____________________________________________________________
Par Value: $_____________________
Interest Rate ______%
Market Value: $ ________________________
CUSIP #: _______________________ Certificate Number(s):______________ Maturity Date: _____________
Certificate of Deposit Number: _________________________________________
Financial Institution Account Number: ___________________________________ (If different than CD Number)
WHICH IS TO BE CLASSIFIED AS A: (Check one type only)
(
)
HCSO Escrow Reserve Deposit - pursuant to A.R.S. § 20-1056
(
)
Ordinary Statutory Deposit required for authority to transact in Arizona
(
)
Retaliatory Deposit pursuant to A.R.S. § 20-230
(
)
Special Statutory Deposit
(
)
Security Deposit for the benefit of ARIZONA policyholders only
(
)
Workers’ Compensation Deposit pursuant to A.R.S. § 23-961
WHOSE INSTRUCTIONS FOR DELIVERY OF RELEASED FUNDS ARE:
A.
The Company authorizes _________________________ of _______________________________________
to take possession of physical securities at a meeting to be scheduled by the Department of Insurance.
B.
Registered mail delivery of physical securities shall be directed to:
Recipient Name and Title:
Company or Firm Name:
Street Address:
City, State, Zip:
C.
Wire Transfer book entry securities or matured security proceeds to:
Institution:
ABA No.:
Credit Account No.:
City and State:
Other Information:
BY AN AUTHORIZED REPRESENTATIVE OF THE COMPANY: (authorizing resolution may be required)
Name:
Title:
Signature:
Date:
CONTACT PERSON:
Title:
Collect or Toll Free Phone:
Fax:
Please call the Trust Deposits Unit at (602) 912-8427 for assistance with completing and filing this form.
Form E126 (Rev. 06/00)
Page 1 of 1
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