Lab 400
Department of Labor
Concord, NH 03301
That we, _________________________________________________________________
as Principal, and _______________________________________________________________
as Fiduciary, are holden and stand firmly bound and obliged unto the State of New Hampshire in
the full and just sum of__________________________________________________________
Dollars ($__________) which is, at present, the aggregate market value of the securities on deposit
with the Fiduciary, to the true payment whereof we bind ourselves, our heirs, administrators,
executors, successors, and assigns, jointly and severally.
WHEREAS the Principal intends to pay direct the benefits in the amounts, manner, and when due
as provided by the Workers' Compensation Law pursuant to RSA 281-A: 5 III, thereby being a
self-insurer for an indefinite period.
WHEREAS the Fiduciary undertakes to act in that capacity and binds himself to comply with the
Workers' Compensation Law, RSA 281-A, as amended, and all rules and regulations promulgated
thereunder, for consideration to be agreed upon by the Principal and Fiduciary.
WHEREAS the Labor Commissioner agrees to discharge his duties and responsibilities with
respect to the said deposit of securities in accordance with the said statute, all rules and
regulations promulgated thereunder, the provisions of this agreement, and his commission.
NOW THEREFORE, the condition of this agreement is such that it shall remain in full force and
effect until other guarantees have been substituted by the Principal in amounts to be approved by
the said Commissioner, except if the Principal ceases to be an employer subject to the said statute
or insures with an insurance carrier pursuant to RSA 281-A: 5 I, in which events the liability of the
Principal and of the Fiduciary shall cease and terminate, except as to such liability which has
accrued during the life of this agreement.
It is understood and agreed that the Fiduciary guarantees the payment of workers' compensation
benefits in amounts, manner, and when due as provided by the said statute and the rules and
regulations promulgated thereunder and that the liability of the Fiduciary by virtue of this
agreement is that of the Principal within the existing monetary value of the said deposit, and that
upon default of the Principal the Fiduciary shall, upon demand of the said Commissioner, dispose
and deposit of securities in sums to be determined by him and from the proceeds make
disbursements as he shall prescribe, such sums and, otherwise, the entire deposit being
unassignable, unattachable and not liable in any way for the debt of the Principal other than that
incurred under the said statute.
WCSI-3 (1/1992) Securities Deposit Agreement Page 1 of 2 Lab 400
It is agreed and understood that the said securities may not be withdrawn by anyone, except at
the peril of the Fiduciary, without prior written authorization of the said Commissioner.
Securities may be substituted or added by endorsement to this agreement.
It is further agreed that the name of the account under this agreement shall be
_____________________________________/State of New Hampshire's
Name of Self-Insurer____________________________________________________________
Workers' Compensation Self-Insurance Program.
This agreement shall be effective on the date of execution by the last signatory.
Notarization (each signature):
Principal (Self-Insurer)
Labor Commissioner
WCSI-3 (1/1992) Securities Deposit Agreement Page 2 of 2