Form A4-40 - Private Self Insurer'S Annual Report - 2000 Page 8
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12NOTE: Self Insured Employer
Page 5
Year Ending December 31, 2000
NOTE:
Complete this page on ALL reports.
VII. SECURITY DEPOSIT
Certificate Number:
Name of Certificate Holder:
A. CURRENT TYPE(S) OF DEPOSIT: Check applicable type(s) of security deposit and provide
A. CURRENT TYPE(S) OF DEPOSIT:
information on each type of deposit posted with the State of California
A. CURRENT TYPE(S) OF DEPOSIT:
as of cutoff date of report (i.e. for full year report, as of December 31, 2000.)
Surety Bond (s)
Original
Penal Sum
Active or
Carrier Name
Bond #
Issue Date
of Bond
Cancelled
$
$
$
$
Surety Bonds Total
Letters of Credit
Type
Total Letter of Credit
Bank Name
Letter of Credit #
Issuing/Confirm
Amount
$
$
$
Letters of Credit Total
$
Securities
Type
ID/or
Date
R-Registered
Issue Name
CUSIP #
Interest Rate
$ Par Value
Issued & Maturity
BE-Book Entry
$
$
$
$
$
$
$
$
Securities Total
$
Cash, Certificate (s) of Deposit
Date
Type
Deposit Institution
Account Number
Cash/CD
Deposited
Amount
$
$
$
$
Cash/CD Total
$
LINE AA: TOTAL DEPOSIT ALL TYPES
$
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