Department of Labor and Industry

Security Deposit/Excess Endorsement

Security Deposit Information & Excess Insurance Endorsements

Security Deposit Information & Excess Insurance Endorsements

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

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 1 Corporate Resolution Self-Insurance. All self-insured employers must complete this form upon initial application. You may substitute your own corporate resolution for ours if you so desire.

Group Resolution (pdf)

Corporate Resolution Group Self-Insurance. All members in a self-insured group must complete this form. This form is required with the new members initial application to join the group.

Group Assumption (pdf)

"Agreement of Assumption and Guarantee of Workers' Compensation & Occupational Disease Liabilities for Self-Insured Group". This department form is for the self-insured group and their members. All members in a self-insured group must complete this form. This form is required with the new members initial application to join the group.

Irrevocable Assignment (pdf)

"Plan 1 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 employer 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

MT endorsements (pdf)

Montana endorsements #1-4 for Excess Insurance. The department requires these Montana endorsements to be included in the specific and aggregate excess workers' compensation insurance policies. These endorsements are not part of a standard work comp excess policy, and must be manually added to the policy by the insurance carrier.

Parent Agreement (pdf)

"Parental Agreement of Assumption and Guarantee of Workers' Compensation & Occupational Disease Liabilities". This department form is required for any self-insured employer that has a parent company.

Surety Bond plan1 (pdf)

Surety Bond department form. The Surety must be listed on the Department of Treasury's listing of Approved Sureties (US Department Circular 570)

Trust Agreement plan1 (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.