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Listing of Life, Accident, and Health Forms

Life, Accident, and Health Main Forms page

Listing of Life, Accident, and Health Forms
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, 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
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
AH024
Individual Short-Term Recovery Care Checklist
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
LAC011
Nonprofit Legal Services Contracts 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
LAH001
Credit Life and Credit Accident and Health Insurance Data Call
PDF English
LAH301
Noninsurance Benefits Checklist
PDF English
LAH302
Total and Partial Assumptions, Mergers, Name Changes, Redomestication, and Demutualization Form Filings Checklist
PDF English
LAH310
Transmittal Checklist for Life/Health Rate and Form Filings
PDF English
LAH311
Transmittal Checklist for Life/Health Miscellaneous Documents
PDF English
LAH312
Transmittal Checklist for HMO Rate and Form Filings
PDF English
LAH313
Transmittal Checklist for Advertising Filings
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
LAHR324
Notice and Consent for HIV-Related Testing
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
LAHR339
CCP Figure 1 - Required Disclosure Statement For All Consumer Choice Health Benefit Plans
PDF English
LAHR344
HMO Reconciliation of Benefits to Schedule of Charges
PDF English
LHL050Rev0609
Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010
PDF English
LHL050Rev1204
Outline of Medicare Supplement Coverage
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
LHL571
Long-Term Care Partnership Agent Training Certification Initial Reporting 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
Prior Authorization of Prescription Drugs
PDF English

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