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.
Group Checklists | Individual Checklists | Employer Certifications | SB 1731 Reimbursement Rate Report
| TDI Form Number | Description | File Format | Language |
|---|---|---|---|
| LHL150 | (Small Employer Carrier Status) Certification |
English | |
| LHL152 | Application to TDI (Risk-Assuming/Reinsured Carrier) |
English | |
| LHL153 | (Annual Listing-Exempt Forms & SEHBPs) Certification |
English | |
| LHL154 | Geographic Service Areas Certification |
English | |
| LHL157 | (Annual Actuarial) Certification To Texas Department of Insurance |
English | |
| LHL158 | Certification to Texas Department of Insurance |
English | |
| LHL159 | Report to Texas Department of Insurance (Private Purchasing Cooperatives) Statement of Amounts Collected and Expenses Incurred |
English | |
| LHL160 | (Large Employer Carrier Status) Certification TO Texas Department of Insurance Relating to Marketing in the Large Employer Market |
English | |
| LHL161 | Geographic Service Areas For Large Employer Carriers Certification To Texas Department of Insurance |
English |
| TDI Form Number | Description | File Format | Language |
|---|---|---|---|
| LHL616 | Health Care Claims Reimbursement Rate Report Annual Data Call Pursuant to 28 TAC ยง21.4506 |
Excel | English |
For more information contact:
Last updated: 11/18/2011
