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.
Numerical Listing of Life, Accident and Health Forms and Checklists
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| LHL050 |
Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010
Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010-Revised date 06/09 |
PDF | English |
| LHL050 |
Outline of Medicare Supplement Coverage
Outline of Coverage - Rev. 12/04 |
PDF | English |
| LHL064 |
Life/Health Earned Premiums Credit Life Insurance
Collect data |
PDF | English |
| LHL065 |
Life/Health Actuarial Reserve Certification Form
Collect data |
PDF | English |
| LHL066 |
Life/Health Inventory Information Form Presumptive Rates
Collect data |
PDF | English |
| LHL069 |
Life/Health Inventory Information Form Deviated Rates
Collect data |
PDF | English |
| LHL071 |
Life/Health Affidavit of Validity of Experience Data Form
Collect data |
PDF | English |
| LHL072 |
Life/Health Earned Premiums Credit Disability Insurance
Collect data |
PDF | English |
| LHL073 |
Life/Health Reconciliation to State Page Credit Life
Collect data |
PDF | English |
| LHL074 |
Life/Health Reconciliation to State Page Credit Disability
Collect data |
PDF | English |
| LHL150 |
(Small Employer Carrier Status) Certification
|
PDF | English |
| LHL152 |
Application to TDI (Risk-Assuming/Reinsured Carrier)
|
PDF | English |
| LHL153 |
(Annual Listing-Exempt Forms & SEHBPs) Certification
|
PDF | English |
| LHL154 |
Geographic Service Areas Certification
|
PDF | English |
| LHL157 |
(Annual Actuarial) Certification To Texas Department of Insurance
|
PDF | English |
| LHL158 |
Certification to Texas Department of Insurance
|
PDF | English |
| LHL159 |
Report to Texas Department of Insurance (Private Purchasing Cooperatives) Statement of Amounts Collected and Expenses Incurred
|
PDF | English |
| LHL160 |
(Large Employer Carrier Status) Certification TO Texas Department of Insurance Relating to Marketing in the Large Employer Market
|
PDF | English |
| LHL161 |
Geographic Service Areas For Large Employer Carriers Certification To Texas Department of Insurance
|
PDF | English |
| LHL187 |
Life/Health Open Records Request Form
Request for company information |
PDF | English |
| LHL235 |
Life/Health Credit Insurance Deviation Request Form
Deviation request form ( CI-DRF ) |
PDF | English |
| LHL251 |
Life/Health Individual Indemnity Consumer Choice Benefit Plans
CCP Figure 1 |
PDF | English |
| LHL253 |
Life/Health Group Indemnity Consumer Choice Benefit Plans
CCP Figure 1 |
PDF | English |
| LHL258 |
Life/Health HGC-1, Health Group Cooperative-1 Annual Health Group Cooperatives Report to TDI
Statement of Amounts Collected and Expense Incurred |
PDF | English |
| LHL265 |
DISCRETIONARY GROUP CHECKLIST
Discrertionary Group Checklist |
PDF | English |
| LHL267 |
Life/Health Accident Only/AD&D Group
Group checklist |
PDF | English |
| LHL268 |
Life/Health Dental Group
Group checklist |
PDF | English |
| LHL269 |
Life/Health Disability/Business Overhead Expense
Group checklist |
PDF | English |
| LHL272 |
Life/Health Hospital Indemnity
Group checklist |
PDF | English |
| LHL280 |
Life/Health Specified Disease
Group checklist |
PDF | English |
| LHL281 |
Life/Health Stop Loss
Group checklist |
PDF | English |
| LHL282 |
Life/Health Supplemental Coverage
Group checklist |
PDF | English |
| LHL283 |
Life/Health Vision
Group checklist |
PDF | English |
| LHL284 |
Life/Health Large/Small Employer Group (includes Consumer Choice Health Benefit Plans)
Group checklist |
PDF | English |
| LHL285 |
Life/Health Long Term Care - Group
Group checklist |
PDF | English |
| LHL286 |
Life/Health Group Health Non-Employer or Member Association
Group checklist |
PDF | 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 |
PDF | English |
| LHL287 |
Life/Health Medicare Supplement/Medicare Select
Group checklist |
PDF | English |
| LHL293 |
Life/Health Accident Accidental Death & Dismemberment (AD&D)
Individual checklist |
PDF | English |
| LHL294 |
Life/Health Basic Hospital Expense, Basic Medical Surgical Expense, Combination Basic Hospital, Medical, Surgical Expense
Individual checklist |
PDF | English |
| LHL295 |
Life/Health Disability Income Protection
Individual checklist |
PDF | English |
| LHL296 |
Life/Health First Diagnosis
Individual checklist |
PDF | English |
| LHL298 |
Life/Health Hospital Indemnity
Individual checklist |
PDF | English |
| LHL299 |
Life/HealthLimited Benefit
Individual checklist |
PDF | English |
| LHL301 |
Life/Health Major Medical Expense
Individual checklist |
PDF | English |
| LHL304 |
Life/Health Specified Disease
Individual checklist |
PDF | English |
| LHL305 |
Life/Health Supplemental Coverage
Individual checklist |
PDF | English |
| LHL307 |
Group and Individual Long-Term Care Checklist
Group and individual checklists |
PDF | 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 |
PDF | English |
| LHL308 |
Life/Health Medicare Supplement/Medicare Select
Individual checklists |
PDF | English |
| LHL314 |
Life/Health Individual Health Rate Filing Requirements
Individual checklist |
PDF | English |
| LHL315 |
Life/Health Annuity Applications
|
PDF | English |
| LHL316 |
Life/Health Annuity Loan Provisions
|
PDF | English |
| LHL317 |
Life/Health Annuities Used to Fund Structured Settlement Options
|
PDF | English |
| LHL318 |
Life/Health Equity Indexed
Equity Indexed checklists |
PDF | English |
| LHL319 |
Life/Health Group Annuities Used as Funding Plans, Guaranteed Investment Contracts (GICs), and Synthetic GICs
|
PDF | English |
| LHL320 |
Life/Health Guaranteed Living Benefit Endorsements/Provisions
|
PDF | English |
| LHL321 |
Life/Health Individual and Group Deferred Annuities
|
PDF | English |
| LHL323 |
Life/Health Single Premium Immediate Annuities
|
PDF | English |
| LHL324 |
Life/Health Roth IRA Endorsements/Provisions
|
PDF | English |
| LHL325 |
Life/Health SIMPLE IRA Endorsements/Provisions
|
PDF | English |
| LHL326 |
Life/Health Guaranteed Minimum Death Benefit
|
PDF | English |
| LHL327 |
Life/Health Variable Annuity Contracts
|
PDF | English |
| LHL328 |
Life/Health Waiver of Surrender Charge Provisions/Riders on Disability/Confinement/Terminal Illness
|
PDF | English |
| LHL335 |
Corporate Owned Life Insurance (COLI) - Individual
Checklist |
PDF | English |
| LHL336 |
Life/Health Corporate Owned Life Insurance (COLI) - Group
Checklist |
PDF | English |
| LHL337 |
Life/Health Extension of Maturity Date Beyond Age 100 or 121, As Applicable
Life insurance checklists |
PDF | English |
| LHL338 |
Life/Health Group Life Insurance
Life insurance checklists |
PDF | English |
| LHL339 |
Life/Health Individual Life Exclusion Riders
Life insurance checklists |
PDF | English |
| LHL341 |
Life/Health Individual Whole Life and Term Insurance Policies
Life insurance checklists |
PDF | English |
| LHL342 |
Life/Health Interest Sensitive Whole Life Policies
Life insurance checklists |
PDF | English |
| LHL343 |
Life/Health Life Applications
Life insurance checklists |
PDF | English |
| LHL344 |
Life/Health No-Lapse Guarantee Provisions
Life insurance checklists |
PDF | English |
| LHL346 |
Life/Health Universal Life Policies
Life insurance checklists |
PDF | English |
| LHL347 |
Life/Health Variable Life Insurance Policies
Life insurance checklists |
PDF | English |
| LHL348 |
Life/Health Reinstatement Due to Mental Incapacity
Life insurance checklists |
PDF | English |
| LHL349 |
Life/Health Individual Modified Guaranteed Investment Contracts Market Value Adjustment Provisions
|
PDF | English |
| LHL350 |
Life/Health Life Illustration Certification and Notification
Life illustration filings |
PDF | English |
| LHL351 |
Life/Health Nonprofit Legal Services Contracts
Nonprofit legal services checklist |
PDF | English |
| LHL356 |
Life/Health Checklists for Assumption/Merger Certificates Life, Annuity and Credit/Accident and Health
|
PDF | English |
| LHL366 |
Notice and Consent for HIV Testing
Consent Form |
PDF | English |
| LHL368 |
Actuarial Certification of Compliance with Chapter 1107, Texas Insurance Code, for Equity Indexed Annuities
Actuarial Certification |
PDF | English |
| LHL369 |
Initial Actuarial Certification of Compliance with Chapter 1107, Texas Insurance Code, for Equity Indexed Annuities
Initial Actuarial Certification |
PDF | English |
| LHL370 |
Additional Insured Benefit Riders Checklist
|
PDF | English |
| LHL372 |
Family Term Riders Checklist
|
PDF | English |
| LHL373 |
Consumer Price Index Riders Checklist
|
PDF | English |
| LHL375 |
Substitute Insured Riders Checklist
|
PDF | English |
| LHL376 |
WAIVER OF PREMIUM RIDERS - UNEMPLOYMENT
Life insurance checklists |
PDF | English |
| LHL377 |
Accidental Death Riders Checklist
|
PDF | English |
| LHL378 |
ANNUALLY RENEWABLE TERM LIFE RIDERS
ANNUALLY RENEWABLE TERM LIFE RIDERS |
PDF | English |
| LHL379 |
Dependent Child Riders Checklist
|
PDF | English |
| LHL384 |
Individual Health Outline of Coverage
Checklist |
PDF | English |
| LHL387 |
Credit Life and Credit Accident and Health Insurance Presumptive Premium Rates
Checklist |
PDF | English |
| LHL393 |
Funding Agreement/Well Plugging
Checklist |
PDF | English |
| LHL395 |
Paid-Up Additions Rider
Checklist |
PDF | English |
| LHL400 |
Accelerated Death Benefits
Checklist |
PDF | English |
| LHL401 |
Prepaid Funeral Insurance Policies/Contracts Checklist
|
PDF | English |
| LHL402 |
Form Health Pool Notice
|
PDF | English |
| LHL404 |
Return of Premium Checklist
Life insurance checklists |
PDF | English |
| LHL405 |
WAIVER OF PREMIUM/MONTHLY DEDUCTION RIDERS (Disability of Insured, Disability of Payor, Death of Payor, Nursing Home Confinement)
Life insurance checklists |
PDF | English |
| LHL406 |
Group Health Blanket Checklist
|
PDF | English |
| LHL407 |
Employer Market Form Filing Checklist
|
PDF | English |
| LHL413 |
Overloan Protection Provisions/Riders
Checklist |
PDF | English |
| LHL414 |
Fraternal Filings Checklist
|
PDF | English |
| LHL415 |
Private Placement Filings Checklist
LHL415 Private Placement Filings Checklist |
PDF | English |
| LHL431 |
30-DAY FREE LOOK CHECKLIST
30-DAY FREE LOOK |
PDF | English |
| LHL560 |
Long-Term Care Insurance Personal Worksheet
LTC Personal Worksheet |
PDF | English |
| LHL561 |
Long-Term Care Insurance Potential Rate Increase Disclosure Form
LTC Potential Rate Increase |
PDF | English |
| LHL562 |
Long-Term Care Insurance Replacement and Lapse Reporting Form
Replacement and Lapse Reporting |
PDF | English |
| LHL563 |
Rescission Reporting Form for Long-Term Care Policies
LTC Rescission Reporting |
PDF | English |
| LHL564 |
Long-Term Care Insurance Claim Denials Reporting Form
LTC Claim Denials Reporting |
PDF | English |
| LHL565 |
Long-Term Care Policies Sold Reporting Form
LTC Policies Sold Reporting |
PDF | English |
| LHL566 |
Long-Term Care Suitability Reporting Form
LTC Suitability Reporting |
PDF | English |
| LHL567 |
Things To Know Before You Buy LTC Insurance
Things You Should Know Before You Buy |
PDF | English |
| LHL568 |
LTC Insurance Suitability Letter
Long-Term Care Insurance Suitability Letter |
PDF | English |
| LHL569 |
Partnership Status Disclosure Notice for LTC Partnership Policies/Certificates
Partnership Status Disclosure Notice |
PDF | English |
| LHL570 |
Long-Term Care Partnership Program Insurer Certification Form
LTC Partnership Program Insurer Certification |
PDF | English |
| LHL571 |
Long-Term Care Partnership Agent Training Certification
LTC Partnership Agent Training Certification |
PDF | English |
| LHL572 |
LTC Partnership Agent Training Certification Form
Long-Term Care Partnership Agent Training Certification Form |
PDF | English |
| LHL573 |
Insurer Certification of Association Compliance With Marketing Standards for LTC Partnership and Non-Partnership
Insurer Certification of Association Compliance With Marketing Standards for Long-Term Care Partnership and Non-Partnership Policies and Certificates |
PDF | English |
| LHL604 |
AGENT REPLACEMENT OF LIFE INSURANCE OR ANNUITIES NOTICE
|
PDF | English |
| LHL605 |
COMPANY REPLACEMENT OF LIFE INSURANCE OR ANNUITIES NOTICE
|
PDF | English |
| LHL606 |
NOTICE REPLACEMENT OF LIFE INSURANCE OR ANNUITIES
|
PDF | English |
| LHL607 |
NONINSURANCE BENEFIT CHECKLIST
|
PDF | English |
| LHL608 |
Health Benefit Plan/Provider Contracting Practices Survey
Health Benefit Plan Survey |
PDF | English |
| LHL609 |
Health Benefit Plan Issuer Hospital Grid
Health Benefit Plan Survey |
PDF | English |
| LHL610 |
Consumer Choice Health Benefit Plans Data Certification
CCP Figure 2 |
PDF | English |
| LHL620 |
Credit Data Call Acknowledgment Receipt
Credit Data Call Acknowledgment Receipt for Years 2006, 2007 and 2008 |
PDF | English |
| LHL621 |
INDIVIDUAL AND GROUP CREDIT LIFE AND CREDIT ACCIDENT AND HEALTH INSURANCE
Credit Life and Credit Accident and Health Checklist |
PDF | English |
| LHL651 |
OPTIONAL - Health Insurance Pools - Notice of Availability of Coverage under the Texas Health Insurance Pool or Under the Pre-Existing Condition Insurance Plan
OPTIONAL - Health Insurance Pools - Notice of Availability of Coverage under the Texas Health Insurance Pool or Under the Pre-Existing Condition Insurance Plan |
PDF | English |
| LHL653 |
Annuity Disclosure Checklist
|
PDF | English |
