Security Agreement For Certificate Of Deposit And Notice Of Security Interest

SECURITY AGREEMENT FOR CERTIFICATE OF DEPOSIT Last Revised 7/08/08 1. 2. DATE: ______________________________ PARTIES: The parties to this agreement are the employer (herein "Grantor") and the Office of Workers' Compensation, Louisiana Workforce Commission, State of Louisiana (herein "OWC"). APPEARANCE OF GRANTOR. Grantor's { } social security number { } federal employer identification number is: _______________ Grantor's (A) Parish (es) in which it does business, and (B) location of its chief executive office are: (A) __________________________________________________ (B) _______________________________________________________________________ 3. 4. SECURITY INTEREST. Grantor grants to OWC a continuing security interest in the property described below (herein "Collateral") to secure the prompt payment of Grantor's workers' compensation liabilities (herein "Obligations"). OBLIGATIONS. The security interest granted herein in the Collateral shall secure the prompt payment of all present and future Obligations, including, but not limited to, prompt payment of workers' compensation payments, the furnishing of medical treatment, or any other requirement under the provisions of the Louisiana Workers' Compensation Act, LSA-R.S. 23:1021 et seq., and any amendments thereto, as well as rules and regulations promulgated in accordance therewith, and, upon the occurrence of a default under this agreement legal expenses and attorney's fees incurred by OWC in collecting or enforcing payment or performance of such Obligations and all funds spent by OWC in preserving or protecting or realizing on the Collateral described herein of Grantor to OWC, pursuant to the provisions of the Louisiana Workers' Compensation Act, and particularly pursuant to the provisions of LSA-R.S. 23:1168 and Rules of the OWC Fiscal Responsibility Unit (herein "Rules") promulgated thereunder. COLLATERAL. The Collateral shall consist of all of the following described property and Grantor's rights, title and interest in such property, whether now owned or hereafter acquired by Grantor and wheresoever located: Certificate of Deposit date _______________, 20____ issued by ____________________ for the account of Grantor in the sum of $____________________ and identified by Certificate (Receipt or Confirmation Advice, if applicable) No. _______________ together with any and all renewals and extensions thereof, all cash and non-cash proceeds of all or any of the foregoing, in whatever form, and all proceeds of such proceeds. All interest shall accrue to the account of, or be collected and transmitted to, the Grantor, provided he is not in default in the payment of compensation or the annual premium tax (as provided for in the above reference Rules) All accessions, accessories, additions, amendments, attachments, modifications, parts, replacements and substitutions to any of the above; All proceeds from any policies of insurance pertaining to any of the above, to the extent authorized by Chapter 9 of the Louisiana commercial Laws of any other applicable 5. 6. American LegalNet, Inc. www.FormsWorkFlow.com law; and All books and records pertaining to any of the above. 7. REPRESENTATIONS, WARRANTIES AND COVENANTS. Grantor represents, warrants and covenants to OWC that: a. Grantor is and shall remain the sole owner of the Collateral; b. Grantor shall defend the Collateral against all claims and demands of all persons at any time claiming any interest therein; c. Grantor shall not amend, extend, modify, replace, or substitute any certificate of deposit constituting the Collateral without the prior consent of OWC as provided in its Rules. d. Grantor has the right and is duly authorized to grant this security interest and to enter into and perform its Obligations under this agreement; e. Grantor has not violated and shall not violate any applicable federal, state, parish, county or municipal statute, regulation or ordinance which may materially and adversely affect its business operations or financial condition or the Collateral' and f. Grantor has not performed any acts or signed any agreements which might prevent OWC from enforcing any of the terms of this agreement or which would limit OWC in any such enforcement. No security agreement or similar or equivalent document or instrument covering all or any part of the Collateral has been executed by Grantor and remains in effect. 8. SALE OF COLLATERAL. Grantor shall not assign, covey, lease, sell, transfer or otherwise dispose of any of the Collateral to any third party without the prior written consent of OWC. ACKNOWLEDGMENT AND OTHER PAPERS. Grantor shall take all actions and execute all papers required by OWC to attach, perfect and maintain its security interest in the Collateral and establish and maintain its right to receive the payment of the proceeds of the Collateral, including, but not limited to, executing and acknowledgments, amendments, and other papers required by Chapter 9 of the Louisiana commercial Laws or other applicable law. Grantor shall pay the costs of filing such papers in all offices wherever filing or recording is deemed by OWC to be necessary or desirable. INQUIRES AND NOTIFICATION TO THIRD PARTIES. Grantor hereby authorizes OWC to contact any third party and make any inquiry pertaining to Grantor's financial condition or the Collateral. In addition, OWC is authorized to provide oral or written notice of its security interest in the Collateral and the obligations and record of financial transactions pertaining thereto any third party. Furthermore, Grantor hereby grants any third party the right to disclose to OWC any records of its financial transactions with Grantor. POWER OF ATTORNEY. In the event or default (as detailed in section 13), Grantor hereby appoints OWC as his attorney-in-fact to endorse Grantor's name on all instruments and other remittances payable to Grantor with respect to the Collateral or other papers pertaining to OWC actions in connection with the Collateral. The powers of attorney described in this paragraph are coupled with an interest and are 9. 10. 11. American LegalNet, Inc. www.FormsWorkFlow.com irrevocable. 12. INSPECTION OF COLLATERAL AND BOOKS AND RECORDS. In addition to reporting requirements or inspection rights established by the Louisiana Workers' Compensation Act and by the Rules, Grantor shall allow OWC or its agents to examine, inspect and make abstracts and copies of the Collateral and Grantor's books and records pertainin