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Fillable Printable Form 207-143-000

Fillable Printable Form 207-143-000

Form 207-143-000

Form 207-143-000

F207-143-000 security interest 8-96
Department of Labor and Industries
Self-Insurance
PO Box 44891
Olympia WA 98504-4891
ACKNOWLEDGEMENT OF SECURITY INTEREST
Name of Deposit Bank
Address
City State ZIP+4
Name of Self-Insurer
UBI Number / Account ID
The above named parties acknowledge that the funds deposited into account _______________________________ at
Number
the bank are solely for the purpose of providing for the payment of workers' compensation benefits and assessments in
the event of default by the self-insurer.
Deposit bank agrees to the following:
1. The account instrument will be registered in the name of ____________________________________________as
escrow agent for the self-insurer.
Escrow Bank Name
2. The account instrument will be held in escrow by the escrow bank until release is authorized in writing by the
Department of Labor and Industries.
3. Notice of maturity of the account instrument will be sent to both the self-insurer and the escrow bank.
4. In the event of a default by the self-insurer on its obligation under Title 51 RCW, title to the funds deposited herein
automatically passes to the Department of Labor and Industries.
5. In the event of a bankruptcy proceeding entered into by the self-insurer or initiated by its creditors, where the self-
insurer defaults on its obligation under Title 51 RCW, the money deposited herein is not the property of the estate of the
debtor. Regardless of whether the bankruptcy proceeding is instituted before or after the default occurs, title to the
money deposited herein passes automatically to the Department of Labor and Industries upon default without requiring
court approval.
Signature of Deposit Bank Representative Signature of Self-Insurer Representative
Title of Deposit Bank Representative
Date of Acknowledgment
Title of Self-Insurer Representative
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