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Texas Department of Insurance
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Listing of Life, Accident, and Health Forms

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TDI Form Number Description File Format Language
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
AH008

Group Health Employer Market Form Filing Checklist - Figure 40, 42, 47, 48, and 50

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
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
AH024

Individual Short-Term Recovery Care Checklist

PDF English
AH025 (Fillable PDF)

Balance billing waiver

Fillable PDF version

PDF English
AH025

Balance billing waiver

PDF English
HMO001

Consumer Choice Evidence of Coverage (EOC) Checklist - Individual Plans

PDF English
HMO002

Consumer Choice Evidence of Coverage (EOC) Checklist - Large Employer and Conversion Plans

PDF English
HMO003

Consumer Choice Evidence of Coverage (EOC) Checklist - Small Employer and Conversion Plans

PDF English
HMO004

Evidence of Coverage (EOC) Checklist - Individual Plans

PDF English
HMO005

Evidence of Coverage (EOC) Checklist - Large Employer and Conversion Plans

PDF English
HMO006

Evidence of Coverage (EOC) Checklist - Small Employer and Conversion Plans

PDF English
HMO007

Evidence of Coverage (EOC) Checklist - Single Health Care Service Plan - Dental Care

PDF English
HMO008

Evidence of Coverage (EOC) Checklist - Single Health Care Service Plan - Vision Care

PDF English
LAC001

Group Annuities Checklist

PDF English
LAC002

Individual Deferred Annuities Checklist

PDF English
LAC003

Single Premium Immediate Annuities Checklist

PDF English
LAC004

Variable Annuities Checklist

PDF English
LAC005

Group Life Insurance Checklist

PDF English
LAC006

Individual Term and Whole Life Checklist

PDF English
LAC007

Universal Life Insurance Checklist

PDF English
LAC008

Variable Life Insurance Checklist

PDF English
LAC009

Corporate Owned Life Insurance Checklist

PDF English
LAC010

Fraternal Filings Checklist

PDF English
LAC012

Private Placement Filings Checklist

PDF English
LAC013

Annuity and Life Applications Checklist

PDF English
LAC014

Life and Annuity Riders, Endorsements, and Amendments Checklist

PDF English
LAC015

Accelerated Death Benefits Checklist

PDF English
LAC016

Additional Insured's Checklist

PDF English
LAC017

Guaranteed Living Benefits Checklist

PDF English
LAC018

Index-Linked Crediting Features Checklist

PDF English
LAC019

Life Exclusions Checklist

PDF English
LAC020

Life Illustration Certification and Notification Checklist

PDF English
LAC021

Market Value Adjustments Checklist

PDF English
LAC022

Prepaid Funeral Filings Checklist

PDF English
LAC023

Return of Premium Checklist

PDF English
LAC024

Waiver of Premium Checklist

PDF English
LAC025

Individual and Group Credit Life and Credit Accident and Health Insurance Checklist

PDF English
LAC026

Life Settlement Forms Checklist

PDF English
LAH301

Noninsurance Benefits Checklist

PDF English
LAH302

Total and Partial Assumptions, Mergers, Name Changes, Redomestication, and Demutualization Form Filings Checklist

PDF English
LAH303

Advertising Product Review Checklist

PDF English
LAH310

Life and Health Transmittal Form

PDF English
LAH311

Life, Health and HMO Miscellaneous Documents Transmittal Checklist

PDF English
LAH312

HMO Transmittal Checklist and Certification Form

PDF English
LAH313

Advertising Transmittal Checklist and Certification Form

PDF English
LAH314

Advertising Annual Certification of Compliance

PDF English
LAH321

Credit Insurance Deviation Request Form

PDF English
LAH322

Actuarial Certification of Compliance for Indexed-Linked Annuities with an Additional Basis Point Reduction

PDF English
LAH323

Life Settlement Provider Data Report

PDF English
LAH345

Mandated Benefits and Mandated Offers Reporting Form

PDF English
LAHR324

Notice and Consent for HIV-Related Testing

PDF English
LAHR330

Small Employer Carrier Status Certification

PDF English
LAHR334

Form Number 1212 Cert Actuarial Annual Small Employer Health Benefit Plan Actuarial Certification - Figure 47

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
LAHR339

CCP Figure 1 - Required Disclosure Statement For All Consumer Choice Health Benefit Plans

PDF English
LAHR339 - Example 1

Employer example of LAHR339 (Form CCP1)

WORD English
LAHR339 - Example 2

Healthcare.gov example of LAHR339 (Form CCP1)

WORD English
LAHR344

HMO Reconciliation of Benefits to Schedule of Charges

PDF English
LHL050

Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or after June 1, 2010

PDF English
LHL050

Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010

This form must be used beginning July 1, 2019.

PDF English
LHL560

Long-Term Care Insurance Personal Worksheet

PDF English
LHL561

Long-Term Care Insurance Potential Rate Increase Disclosure Form

PDF English
LHL562

Long-Term Care Insurance Replacement and Lapse Reporting Form

PDF English
LHL563

Long-Term Care Insurance Recission Reporting Form

PDF English
LHL564

Long-Term Care Insurance Claim Denials Reporting Form

PDF English
LHL565

Long-Term Care Insurance Policies Sold Reporting Form

PDF English
LHL566

Long-Term Care Insurance Suitability Reporting Form

PDF English
LHL567

Things To Know Before You Buy Long-Term Care Insurance

PDF English
LHL568

Long-Term Care Insurance Suitability Letter

PDF English
LHL569

Partnership Status Disclosure Notice for Long-Term Care Partnership Policies/Certificates

PDF English
LHL570

Long-Term Care Partnership Program Insurer Certification Form

PDF English
LHL572

Long-Term Care Partnership Agent Training Certification Form Annual Report

PDF English
LHL573

Insurer Certification of Association Compliance with Marketing Standards for Long-Term Care Partnership and Non-Partnership Policies and Certificates

PDF English
LHL610

Consumer Choice Health Benefit Plans Data Certification

PDF English
NOFR001

Prior Authorization of Health Care Services

PDF English
NOFR002

Texas Standard Prior Authorization Request Form for Prescription Drug Benefits

PDF English

For more information, contact: LifeHealth@tdi.texas.gov