Depository and dividend forms
Effective February 1, 2000, this office will no longer provide hard copies of the deposit or withdrawal request forms, or the depositary agreements. You can find links to these forms below or request them via email to SusanM@oic.wa.gov. The forms must be presented to this office as three hard-copy originals.
CUSIP numbers are needed to identify the securities on deposit. Please provide detailed information of the security as required on the deposit and withdrawal-request forms.
Any withdrawal or transfer of funds or securities held on deposit must be approved in writing by this office before the actual transfer.
- Deposit Request (PDF, 30KB) - State Deposit Trust Account
- Depositary Trust Agreement (PDF, 77KB)
- Withdrawal Request (PDF, 26KB) - State Deposit Trust Account
- Notification of Dividend from Washington Health Carriers (PDF, 70KB)
- Notification of Dividend from Washington Insurers (Word, 31KB)
Submit forms to:
Company Supervision Division
Office of the Insurance Commissioner
PO Box 40259
Olympia, WA 98504-0259