Form E125 - Notice Of Trust Deposit Delivery June 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 DELIVERY
PLEASE APPROVE DELIVERY OF THE FOLLOWING SECURITY FOR THE ACCOUNT OF THE
ARIZONA STATE TREASURER ON BEHALF OF THE DIRECTOR OF INSURANCE, WHO WILL, IN
TURN, HOLD 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:_________________________ Automatic Renewal? (check one): ( )YES ( )NO
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
TO BE DELIVERED FOR DEPOSIT BY: (Check or complete A, B or C)
A.
Personal____ courier____ or mail____ (check one) delivery to the Arizona Department of Insurance.
B.
____ (check) Delivery to the office of the Arizona State Treasurer at a meeting to be scheduled by the
Arizona Department of Insurance. (Applicable to certificates of deposit only)
C.
Wire transfer delivery in accordance with Trust Deposit Instructions Supplement A (Form E004) from:
Broker or Sender:
ID or ABA No.:
City: ________________________
State:
Settlement Date:
AS INSTRUCTED BY AN AUTHORIZED REPRESENTATIVE OF THE INSURANCE COMPANY:
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 E125 (Rev. 06/00)
Page 1 of 1
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