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 |
|---|---|---|---|
| LHL258 | Life/Health HGC-1, Health Group Cooperative-1 Annual Health Group Cooperatives Report to TDI Statement of Amounts Collected and Expense Incurred |
English | |
| LHL267 | Life/Health Accident Only/AD&D Group Group checklist |
English | |
| LHL268 | Life/Health Dental Group Group checklist |
English | |
| LHL269 | Life/Health Disability/Business Overhead Expense Group checklist |
English | |
| LHL272 | Life/Health Hospital Indemnity Group checklist |
English | |
| LHL280 | Life/Health Specified Disease Group checklist |
English | |
| LHL281 | Life/Health Stop Loss Group checklist |
English | |
| LHL282 | Life/Health Supplemental Coverage Group checklist |
English | |
| LHL283 | Life/Health Vision Group checklist |
English | |
| LHL284 | Life/Health Large/Small Employer Group (includes Consumer Choice Health Benefit Plans) Group checklist |
English | |
| LHL285 | Life/Health Long Term Care - Group Group checklist |
English | |
| LHL286 | Life/Health Group Health Non-Employer or Member Association Group checklist |
English | |
| LHL287 | 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued - for Plans Sold for Effective dates on of after June 1, 2010 |
English | |
| LHL287 | Life/Health Medicare Supplement/Medicare Select Group checklist |
English | |
| LHL406 | Group Health Blanket Checklist |
English |
| TDI Form Number | Description | File Format | Language |
|---|---|---|---|
| LHL293 | Life/Health Accident Accidental Death & Dismemberment (AD&D) Individual checklist |
English | |
| LHL294 | Life/Health Basic Hospital Expense, Basic Medical Surgical Expense, Combination Basic Hospital, Medical, Surgical Expense Individual checklist |
English | |
| LHL295 | Life/Health Disability Income Protection Individual checklist |
English | |
| LHL296 | Life/Health First Diagnosis Individual checklist |
English | |
| LHL298 | Life/Health Hospital Indemnity Individual checklist |
English | |
| LHL299 | Life/HealthLimited Benefit Individual checklist |
English | |
| LHL301 | Life/Health Major Medical Expense Individual checklist |
English | |
| LHL304 | Life/Health Specified Disease Individual checklist |
English | |
| LHL305 | Life/Health Supplemental Coverage Individual checklist |
English | |
| LHL307 | Group and Individual Long-Term Care Checklist Group and individual checklists |
English | |
| LHL308 | 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued - for Plans Sold for Effective dates on of after June 1, 2010 |
English | |
| LHL308 | Life/Health Medicare Supplement/Medicare Select Individual checklists |
English | |
| LHL314 | Life/Health Individual Health Rate Filing Requirements Individual checklist |
English | |
| LHL384 | Individual Health Outline of Coverage Checklist |
English |
| 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
