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

Accident and Health Checklists, Forms and Rate Report

Accident and Health Checklists, Forms and Rate Report
TDI Form Number Description File FormatLanguage
AH001
Group Health Product Requirements Checklist
PDF English
AH002
Group Health Large and Small Employer Requirements Checklist
PDF English
AH003
Group Health Non-Employer or Member Association Checklist
PDF English
AH004
Group Health Accident Only/Accidental Death and Dismemberment (AD&D) Checklist
PDF English
AH005
Group Health Discretionary Group Checklist
PDF English
AH006
Group Blanket Accident and Health Checklist
PDF English
AH007
Group Health Disability / Business Overhead Expense Checklist
PDF English
AH008
Group Health Employer Market Form Filing Checklist - Figure 40, 42, 43, 44, 47, 50 and 51 Filings
PDF English
AH009
Group Health Specified Disease Checklist
PDF English
AH010
Group Health Stop Loss Checklist
PDF English
AH011
Group and Individual Dental and Vision Checklist
PDF English
AH012
Group and Individual Long-Term Care Checklist
PDF English
AH013
Group and Individual Health Supplemental Coverage Checklist
PDF English
AH014
Group and Individual Health Medicare Supplement and Select Checklist
PDF English
AH015
Individual Health Product Requirements Checklist
PDF English
AH016
Individual Health Major Medical Checklist
PDF English
AH017
Individual Health Limited Benefit Checklist
PDF English
AH018
Individual Health Accident Only / Accidental Death and Dismemberment (AD&D) Checklist
PDF English
AH019
Individual Health Basic Hospital or Medical-Surgical Expense, Combination Basic Hospital, Medical, Surgical Expense Checklist
PDF English
AH020
Individual Health First Diagnosis or Critical Illness and Specified Disease Checklist
PDF English
AH021
Individual Health Rate / Rate Increase Filing Requirements Checklist
PDF English
AH022
Individual and Group Health Disability Income Protection Checklist
PDF English
AH023
Individual and Group Health Hospital Indemnity Checklist
PDF English
LAHR330
Small Employer Carrier Status Certification
PDF English
LAHR331
Election and Application to be a Risk-Assuming or Reinsured Carrier
PDF English
LAHR332
Form Number 1212 CERT ANN LIST-OTHER/SEHBP
PDF English
LAHR334
Form Number 1212 CERT ACTUARIAL Annual Small Employer Health Benefit Plan Actuarial Certification
PDF English
LAHR335
Form Number 1212 CERT DATA Annual Small Employer Health Benefit Plan Report
PDF English
LAHR337
Large Employer Carrier Status Certification
PDF English
LHL610
Consumer Choice Health Benefit Plans Data Certification
PDF English

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