Form Si-32 - Assignment Of Securities

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SAMPLE (Held by Bank or Savings & Loan)
ASSIGNMENT OF SECURITIES
Agreement made this
day of
, 20
between
(name of
self-insurer) and the Director of Workers' Compensation, 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, 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, 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, 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 Monitoring and Audit,
Self-Insurance Section
For the Director of Workers' Compensation,
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)
(phone no.)
Form SI-32 (9/96)

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