Certificate of Deposit Assignment Agreement - ERD Home

1 Montana Department of Labor & IndustryEmployment Relations DivisionWorkers' Compensation Regulation BureauPO Box 8011 Helena, MT 59604-8011 Certificate # _____CERTIFICATE of Deposit Assignment AGREEMENTIRREVOCABLE ASSIGNMENTSPECIAL POWER of ATTORNEYAGREEMENT with FINANCIAL purpose of tendering this Certificate of Deposit ( ) Assignment is for ( theInsurer )_____, of ( Address )_____ (hereinafter called theInsurer) anInsurerunder compensation plan the Montana Workers Compensation Acts, tofurnish to the Montana Department of Labor & Industry, Employment Relations Division(hereinafter calledthe Department) security for the protection and guarantee of payment of past,present, and future workers compensation and occupational disease liabilities owed by : A Certificate must be held in the name of theInsurerand theDepartment.

2 Thecertificate must be automatically renewable. No certificates at a single financial institution may befor more than $100,000 (one hundred thousand dollars). Submit the actual Certificate and thisoriginal Assignment Agreement to the Department. Distribute copies of the Assignment Agreementto the Financial Institution and to good and valuable consideration, theInsurerirrevocably assigns all of its right, title andinterestin the jointly held to the Department in trust for claimants of theInsurer, as of thisdate. As of the date of this Assignment , the shall be deemed property of the Department andnot property of Assignment creates a third-party beneficiary contract . The third party beneficiaries are theemployees of the Department notifies the Financial Institution otherwise, periodic interest on the be paid directly to theInsurer.

3 However, at any time in its sole discretion, the Department maysell or liquidate the and apply the money as appropriate. In that regard, theInsurerherebyauthorizes the Financial Institution to pay over the entire proceeds from such sale or liquidationincluding any earned and unpaid interest on the to the Department upon request. TheInsurerhereby waives any and all claims it might have against the Financial Institution for selling orliquidating the and paying all of the money to the all workers compensation and occupational disease liabilities for which theInsureris liableas aPlan No. 2are discharged by theInsurer, the MontanaInsuranceGuarantyFund, or by theDepartment using the money generated from selling or liquidating this , the remainingproceeds, if any, willbe refunded to theInsureror otherwise disbursed pursuant to disputes relating to this Assignment shall be decided in the courts of Montana pursuant toMontana law.

4 It is mutually agreed that venue shall be in Lewis and Clark Countyand that eachparty will pay their own attorney fees and legal , as the registered owner of each , does herebyirrevocably constitute and appointthe Department its true and lawful attorney in factto sign and/or endorsein its name, place andstead each in whatever manner is necessary to negotiate the , selling or liquidating it, andhaving the full sum thereof paid directly and solely to the special power of attorney shall not be affected by the subsequent insolvency or incapacity oftheInsurer. This special power of attorney cannot be revoked or amended by theInsurer. Thisspecial power of attorney will remain in effect ratifies and confirms whatever action the Department takes as attorney in factby virtue of this this _____ day of _____, _____.

5 (Corporate Seal)_____Plan No. 2 InsurerBy:_____Signature_____Typed Name and TitleState of _____ )(Notary Seal)) ssCounty of _____ ) onthis _____ day of _____, _____,before me _____personally appeared _____[for person signing on behalf ofInsurer] known to me, orprovided to me to be, and subscribed to before Public for State of _____Residing at _____, commission expires on 2 of 4_____Financial Institution NameCertificate/Account Number_____Contact Person or PositionTelephone NumberFAX Number_____Street or POBoxCityStateZIPA greementwithFinancial Institution Issuing Certificate of DepositFor good and valuable consideration, the parties agree Agreement guarantees that the Montana Department of Labor & Industry, EmploymentRelations Division (hereinafter called the Department) can cash the Certificate of Deposit ( )

6 Atany time and that the Financial Institution will pay the entire principal and unpaid interest, less anypenalty for early withdrawal, to the Department upon shall be a Department letter requesting a cashier s check made payable to the letter will have enclosed the original or other paperwork showing ownership and a copyof this Agreement . The Financial Institution shall issue and mail a cashier s check within twenty(20) days of the date of the Department s demand s bankruptcy, insolvency, or other difficulties of whatsoever kind will not alter theFinancial Institution s obligations in this Agreement . Those events shall in no way prevent, hinder,delay or excuse the prompt payment of the full amount of the with unpaid interest, less anypenalties, to the Department.

7 Regardless of abankruptcy or any other dispute, which might arise,the Financial Institution shall pay the Department as agreed herein. If future events or disputesinvolving the arise, those shall be resolved between theInsurerand the Department and, ifpossible, without the Financial Institution's involvement or Financial Institution will not under any circumstances return or release the principal amount ofthe to theInsureror reissue the to theInsurerfor any reason unless authorized to do so inwriting by an officer of the disputes relating to this Agreement shall be decided in the courts of Montana pursuant toMontana law. It is mutually agreed that venue shall be in Lewis and Clark County and that eachpartywill pay their own attorney fees and legal 3 of 4 DATED this _____ day of _____, InstitutionBy:_____Signature_____Typed Name and Title(Notary Seal)State of _____ )) ssCounty of _____ ) onthis _____ day of _____, _____,before me _____personally appeared _____[for person signing on behalf of Financial Institution] knownto me, or provided to me to be, and subscribed to before Public for State of _____Residing at _____, commission expires on 4 of 4