Department of Labor and Industry

Plan 2 Security Deposit Forms

Security Deposit Information & Excess Insurance Forms

Plan 2 Security Deposit Information & Forms

General disclaimer - department forms require exact wording

You may fill out the forms electronically. We do require a hard copy of the forms with original signatures.

Book Entry (pdf)

Book Entry Requirements - General information on book entry deposits on government securities such as treasury notes. Please see related information in Corporate Resolution, Irrevocable Assignment, and Trust Agreement.

Certificate Deposit Agreement (pdf)

Certificate of Deposit Agreement form. Department form required for Certificate of Deposits.

Corp Resolution (pdf)

Plan 2 Corporate Resolution. All Plan 2 Carriers must complete this form upon initial application. You may substitute your own corporate resolution with approval of the department.

Irrevocable Assignment (pdf)

"Plan 2 Irrevocable Assignment of Securities and Special Power of Attorney". The Irrevocable Assignment of Securities provides a detailed description of the security including the CUSIP number. Once your trust account is established, this is the only document you must submit when replacing a maturing security. This is for government securities such as Treasury Notes. Please see related information in book entry general information.

Letter Credit (pdf)

Letter of Credit - exact wording required for banking institutions.Please see related information in the Memorandum of Understanding.

Memorandum of Understanding (pdf)

The Memorandum of Understanding Letter of Credit must be completed by the carrier and returned to the department.

Our security file is not complete until both the Letter of Credit and the Memorandum of Understanding are returned to our office

Trust Agreement plan2 (pdf)

Trust Agreement. The Trust Agreement establishes a trust account with the self-insured employer and the Trust Company. Please see related information in book entry general information.