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You are here: www.tdi.texas.gov . forms . form10accident

Accident and Health Checklists, Forms and Rate Report

This is one of several pages linking to a central repository of forms used by TDI customers. Use the search or Forms by Type links on the Forms Home Page or scan through our form listings.

Accident and Health Checklists, Forms and Rate Report
TDI Form Number Description File FormatLanguage
LHL150
(Small Employer Carrier Status) Certification
PDFEnglish
LHL152
Application to TDI (Risk-Assuming/Reinsured Carrier)
PDFEnglish
LHL153
(Annual Listing-Exempt Forms & SEHBPs) Certification
PDFEnglish
LHL154
Geographic Service Areas Certification
PDFEnglish
LHL157
Figure 47 Annual Actuarial Certification
Actuarial Certification for Small Employer Health Benefit Plans
PDFEnglish
LHL158
Figure 48 Annual Certification – Small Employer
For Reporting on Small Employer Health Benefit Plans
PDFEnglish
LHL159
Report to Texas Department of Insurance (Private Purchasing Cooperatives) Statement of Amounts Collected and Expenses Incurred
PDFEnglish
LHL160
(Large Employer Carrier Status) Certification TO Texas Department of Insurance Relating to Marketing in the Large Employer Market
PDFEnglish
LHL161
Geographic Service Areas For Large Employer Carriers Certification To Texas Department of Insurance
PDFEnglish
LHL258
HGC-1, Health Group Cooperative-1 Annual Health Group Cooperatives Report to TDI
Statement of Amounts Collected and Expense Incurred
PDFEnglish
LHL265
Discretionary Groups Checklist
PDFEnglish
LHL266
Group Health Product Requirements Checklist
PDFEnglish
LHL267
Accident Only/AD&D Group Checklist
PDFEnglish
LHL269
Disability/Business Overhead Expense Checklist
PDFEnglish
LHL270
Individual and Group Health Disability Income Protection Checklist
PDFEnglish
LHL271
Group and Individual Dental and Vision Checklist
PDFEnglish
LHL273
Group and Individual Health Supplemental Coverage Checklist
PDFEnglish
LHL274
Individual and Group Health Hospital Indemnity Checklist
PDFEnglish
LHL280
Specified Disease Checklist
PDFEnglish
LHL281
Stop Loss Checklist
PDFEnglish
LHL284
Large/Small Employer Group Checklist (includes Consumer Choice Health Benefit Plans)
PDFEnglish
LHL286
Group Health Non-Employer or Member Association Checklist
PDFEnglish
LHL293
Accident Accidental Death & Dismemberment (AD&D) Checklist
PDFEnglish
LHL294
Basic Hospital Expense, Basic Medical Surgical Expense, Combination Basic Hospital, Medical, Surgical Expense Checklist
PDFEnglish
LHL296
First Diagnosis Checklist
PDFEnglish
LHL299
Individual Health Limited Benefit Checklist
PDFEnglish
LHL301
Major Medical Expense Checklist
PDFEnglish
LHL302
Individual Product Requirements Checklist
PDFEnglish
LHL309
Group and Individual Health Medicare Supplement and Select Checklist
PDFEnglish
LHL310
Group and Individual Long-Term Care Checklist
PDFEnglish
LHL314
Individual Health Rate Filing Requirements Checklist
PDFEnglish
LHL406
Group Health Blanket Checklist
PDFEnglish
LHL407
Employer Market Form Filing Checklist
PDFEnglish
LHL610
Consumer Choice Health Benefit Plans Data Certification
PDFEnglish
LHL616
Health Care Claims Reimbursement Rate Report
Instructions for Annual Data Call Pursuant to 28 TAC §21.4506
EXCELEnglish


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Last updated: 09/19/2014

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