Texas Department of Insurance

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Life & Health Other Forms Listing

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.

Life Health Main Forms Page | Other Forms | Optional Forms

   

Other Forms
TDI Form NumberDescriptionFile FormatLanguage
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		 PDFEnglish
LHL050 Outline of Medicare Supplement Coverage
Outline of Coverage - Rev. 12/04		 PDFEnglish
LHL187 Life/Health Open Records Request Form
Request for company information		 PDFEnglish
LHL251 Life/Health Individual Indemnity Consumer Choice Benefit Plans
CCP Figure 1		 PDFEnglish
LHL253 Life/Health Group Indemnity Consumer Choice Benefit Plans
CCP Figure 1		 PDFEnglish
LHL258 Life/Health HGC-1, Health Group Cooperative-1 Annual Health Group Cooperatives Report to TDI
Statement of Amounts Collected and Expense Incurred		 PDFEnglish
LHL265 DISCRETIONARY GROUP CHECKLIST
Discrertionary Group Checklist		 PDFEnglish
LHL318 Life/Health Equity Indexed
Equity Indexed checklists		 PDFEnglish
LHL351 Life/Health Nonprofit Legal Services Contracts
Nonprofit legal services checklist		 PDFEnglish
LHL356 Life/Health Checklists for Assumption/Merger Certificates Life, Annuity and Credit/Accident and Health
 PDFEnglish
LHL366 Notice and Consent for HIV Testing
Consent Form		 PDFEnglish
LHL401 Prepaid Funeral Insurance Policies/Contracts Checklist
 PDFEnglish
LHL402 Form Health Pool Notice
 PDFEnglish
LHL407 Employer Market Form Filing Checklist
 PDFEnglish
LHL414 Fraternal Filings Checklist
 PDFEnglish
LHL415 Private Placement Filings Checklist
LHL415 Private Placement Filings Checklist 		PDFEnglish
LHL431 30-DAY FREE LOOK CHECKLIST
30-DAY FREE LOOK		 PDFEnglish
LHL560 Long-Term Care Insurance Personal Worksheet
LTC Personal Worksheet		 PDFEnglish
LHL561 Long-Term Care Insurance Potential Rate Increase Disclosure Form
LTC Potential Rate Increase 		PDFEnglish
LHL562 Long-Term Care Insurance Replacement and Lapse Reporting Form
Replacement and Lapse Reporting		 PDFEnglish
LHL563 Rescission Reporting Form for Long-Term Care Policies
LTC Rescission Reporting		 PDFEnglish
LHL564 Long-Term Care Insurance Claim Denials Reporting Form
LTC Claim Denials Reporting		 PDFEnglish
LHL565 Long-Term Care Policies Sold Reporting Form
LTC Policies Sold Reporting		 PDFEnglish
LHL566 Long-Term Care Suitability Reporting Form
LTC Suitability Reporting		 PDFEnglish
LHL567 Things To Know Before You Buy LTC Insurance
Things You Should Know Before You Buy 		PDFEnglish
LHL568 LTC Insurance Suitability Letter
Long-Term Care Insurance Suitability Letter		 PDFEnglish
LHL569 Partnership Status Disclosure Notice for LTC Partnership Policies/Certificates
Partnership Status Disclosure Notice		 PDFEnglish
LHL570 Long-Term Care Partnership Program Insurer Certification Form
LTC Partnership Program Insurer Certification 		PDFEnglish
LHL571 Long-Term Care Partnership Agent Training Certification
LTC Partnership Agent Training Certification		 PDFEnglish
LHL572 LTC Partnership Agent Training Certification Form
Long-Term Care Partnership Agent Training Certification Form		 PDFEnglish
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		 PDFEnglish
LHL604 AGENT REPLACEMENT OF LIFE INSURANCE OR ANNUITIES NOTICE
 PDFEnglish
LHL605 COMPANY REPLACEMENT OF LIFE INSURANCE OR ANNUITIES NOTICE
 PDFEnglish
LHL606 NOTICE REPLACEMENT OF LIFE INSURANCE OR ANNUITIES
 PDFEnglish
LHL607 NONINSURANCE BENEFIT CHECKLIST
 PDFEnglish
LHL608 Health Benefit Plan/Provider Contracting Practices Survey
Health Benefit Plan Survey		 PDFEnglish
LHL609 Health Benefit Plan Issuer Hospital Grid
Health Benefit Plan Survey		 PDFEnglish
LHL610 Consumer Choice Health Benefit Plans Data Certification
CCP Figure 2		 PDFEnglish
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		 PDFEnglish
Other Forms
TDI Form NumberDescriptionFile FormatLanguage
LHL640 Quarterly Consumer Information Data Call
Quarterly reporting form for Accident & Health and HMO experience in Texas		 PDFEnglish
LHL657 Mandated Benefits Data Call
Annual reporting form for Mandated Benefits Data Call		 PDFEnglish

   


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