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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.

Life Health Main Forms Page

 

Group Checklists
TDI Form Number Description File FormatLanguage
LHL258 HGC-1, Health Group Cooperative-1 Annual Health Group Cooperatives Report to TDI
Statement of Amounts Collected and Expense Incurred
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
LHL309 Group and Individual Health Medicare Supplement and Select Checklist
PDFEnglish
LHL310 Group and Individual Long-Term Care Checklist
PDFEnglish
LHL406 Group Health Blanket Checklist
PDFEnglish

 

Individual Checklists
TDI Form Number Description File FormatLanguage
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
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 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

 

Consumer Choice Plans
TDI Form Number Description File FormatLanguage
LHL610 Consumer Choice Health Benefit Plans Data Certification
PDFEnglish

 

Employer Certifications
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
LHL407 Employer Market Form Filing Checklist
PDFEnglish
   
SB 1731 Reimbursement Rate Report
TDI Form Number Description File Format Language
LHL616 Health Care Claims Reimbursement Rate Report
Annual Data Call Pursuant to 28 TAC §21.4506
Excel English

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Last updated: 03/14/2014



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