E125 (Rev. 2020-03-02)
ARIZONA DEPARTMENT OF INSURANCE SECURITY DEPOSIT FORM
This form must be completed prior to all deliveries to Union Bank.
MAIL
MUFG Union Bank, N.A.
350 California Street, 17th Floor
San Francisco, CA 94104
FAX
(877) 833-8854
EMAIL
Arizona-Union@unionbank.com
PHONE
(800) 962-1784
Union Bank Account Name: Union Bank Account Number:
Company Contact: Company Contact Telephone:
Delivery Date: Amount of Par for Deposit: $
Buy/Free Deliver Price: Trade Date: Settlement Date:
Principal: UNITS: Cost Basis:
Net Amount: Interest or Commissions:
Broker Name & Number: Broker Telephone Number:
Type of Security (check one) Complete the information below - One form per security asset required.
Please provide detailed security information. For a security other than a U. S. Treasury Obligation please provide the rating
information (below) and verify that the security meets the criteria of Eligible Securities as defined on Appendix A of your Custody
Agreement Form E003.
Security Name CUSIP
Security Rate
Security Issue Date: Security Maturity Date:
Rating Source:
Standard & Poor’s
Rating / As of date
Moody’s Rating /
As of Date
Equivalent NAIC
Designation
U. S. Treasury Obligation deliver to:
Federal Reserve Bank:
FRB Eligible Securities Only:
UNION BK LA/TRUST
ABA #: 122000496
For Credit to Account #______________________
DTCC Eligible Security deliver to:
MUFG Union Bank, N.A.
DTC Participant 2145
For Credit to Account #
Agent Bank ID #: 27978
Institutional ID #: 15810
PLEASE NOTE - CASH IS ONLY ACCEPTED TO: FACILITATE NEW SECURITY PURCHASES AND TRADES, OR HOLD AS PRINCIPAL FUNDS
IN A WORKERS’ COMPENSATION DEPOSIT
CASH WIRE
MUFG Union Bank, N.A.
Monterey Park, CA 91755
TRUSF Branch 09569
ATTN: Domestic Custody
ABA # 122000496
For Credit to Account #:__________________________
(Insert Trust account# in the “BNF_ID” or Beneficiary ID field)
Account Name: _________________________________________________________________
Book Entry or DVP: Forward to Union Bank on Trade Date
By signature below you are certifying that the security described above, meets the criteria of the “Arizona Department of
Insurance Form E003, Appendix A Eligible Securities”
Authorized Signature on File with Union Bank Printed Name & Title Date
