Form Fin462 - Workers' Comp Self-Insured Group Pledge/trust Document Form - Texas Department Of Insurance

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FIN462 | 0415
Bank Letterhead
Workers’ Compensation Self-Insured Group
PLEDGE/TRUST
SECTION_____________________________, LABOR CODE
_____ BOOK ENTRY SECURITY
_____ PHYSICAL SECURITY
(reference what type of security)
__________________________________________
(Name of Company)
Security: ____________________________________
Amount: ____________________________________
Maturity Date: ________________________________
Rate: _______________________________________
Cusp No.:___________________________________
The said company desires to deposit with the Comptroller of Public Accounts, State of Texas, through the
Commissioner of Insurance, the security which is registered in the name of the company duly designated
bank/custodian and which is described above.
The said security has been pledged to the Commissioner of Insurance of the State of Texas and a safekeeping receipt
placed with the Comptroller of Public Accounts, State of Texas.
______________________________________ and ______________________________________
(Name of Company)
(Name of Bank)
certify to the following:
(1) that no prior liens or assignments have been effected or recorded on the records of the bank.
(2) that __________________________________ pledged the referenced security
(Name of Company)
instrument to the Texas Department of Insurance and ____________________________
(Name of Bank)
has recorded on its books that the security(ies) is/are pledged to and held for the benefit of the Texas
Department of Insurance; and
(3) that the Bank will not release or exchange the deposit instrument until so authorized by the Texas Department
of Insurance.
Texas Department of Insurance |
1/2

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