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Agent / Adjuster Forms

This is one of several pages linking to a central repository of forms used by TDI customers. Use the search or Forms by Program/Division links on the Forms Home Page or scan through our form listings.

 

Web Enabled Agent/Adjuster Application Forms
Description File Format
Electronic Resident Agent Application
(This is for an Individual applying for a General Lines, Property and Casualty or Life, Accident,Health and HMO only.)
Electronic Resident Application Process Tutorial
(Select this link to view the Electronic Resident Application Process Tutorial.)
Web Enabled
Electronic Non-resident Application
(Individual or Entity: Links to NIPR, at the Texas instruction page for the electronic application. That page is linked to a Use Agreement page. The "Agree" button links to the actual application.)
Web Enabled
Licensing Application to Renew License
Renew License Online
Web Enabled
NIPR Electronic Address Change Request
(For in-state address changes, an agent or adjuster can use this tool to simultaneously provide an address change notification to all state insurance departments where the agent or adjuster is licensed. There is no charge for the service.)
Web Enabled
Agent/Adjuster Application Forms
TDI Form Number Description File FormatLanguage
FastForm for electronic fingerprint appointment FastPass Form for electronic fingerprint appointment
Rev 1/2013
PDFEnglish
FastForm for fingerprint card Fingerprint Card Scan Authorization Form to submit with fingerprint card
Rev 1/2013
PDFEnglish
FIN506 Licensing - Individual Application for Insurance License
Used by individuals not required to qualify by examination. Previously, form number LI011. Rev 3/2012
PDFEnglish
FIN507 Licensing Application for Insurance Agency License
Used by corporations, partnerships, depository institutions and other business entity eligible for an insurance agency license under the provisions of the Texas Insurance Code. Rev 3/2012
PDFEnglish
FIN510 Licensing Application for Reinsurance Intermediary License
For individuals and entities to apply for a Reinsurance Intermediary License under the provisions of TIC, Chapter 4152. Rev 3/2012
PDFEnglish
FIN511 Licensing Reinsurance Intermediary Biographical Affidavit
To register individuals to be associated to a Reinsurance Intermediary License. Rev 3/2012
PDFEnglish
FIN535 Public Insurance Adjuster Contract form
This contract form is prescribed by the Texas Department of Insurance to satisfy contract requirements for Public Insurance Adjusters effective January 01, 2014.
PDFEnglish
LHL202 Licensing Corporate Insurance Agents Bond (AKA Insurance Agency Bond)
Method of showing proof of financial responsibility to obtain corporate license.
PDFEnglish
LHL250 Annual Nonresident Public Insurance Adjuster Affidavit
Fill-in On Screen and Print
PDFEnglish
LHL256 Licensing Public Insurance Adjuster Bond
Certifies that the persons listed on the form are bound to the Texas Department of Insurance in the sum of $10,000 as specified at 28 Texas Administrative Code ยง19.705.
PDFEnglish
LHL627 Licensing Reinsurance Intermediary Agent For Service or Process Form
Nonresident Reinsurance Intermediary License applicant or licensee must use this form to appoint a Texas resident on whom a notice or order or process may be served.
PDFEnglish
LHL628 Licensing Reinsurance Intermediary Bond
Method of showing proof of financial responsibility for a Reinsurance intermediary License.
PDFEnglish
li004 Speciality Insurance License Application
PDFEnglish

 

Continuing Education Forms
TDI Form Number Description File FormatLanguage
FIN519 CE Automatic Fines Transmittal
Continuing Education Fines
PDFEnglish
LHL212 Application for Provider Registration
Application to become a continuing education provider.
PDFEnglish
LHL213 Application for Course Certification
Application for certification of PE or CE course.
PDFEnglish
LHL216 CE Exemption or Extension
Application for licensee CE Exemption or Extension.
PDFEnglish
LHL240 Course Assignment Form
Allows an existing provider to assign the right to give its course to another existing provider. Both must have active provider registrations.
PDFEnglish
LHL367 Provider Renewal and Information Change Form
Application for Provider Renewal or Change of Contact Information.
PDFEnglish
LHL386 Provider Audit Affidavit
Used only by continuing education providers
PDFEnglish
LHL615 Licensee Request
TEXAS Qualifying Continuing Education Credit
PDFEnglish
LHL617 Request for Association Credit Accepted by TDI
PDFEnglish
NA CE Example Course Evaluation
Sample Only
PDFEnglish

 

Discount Heath Care Program Operator Forms
TDI Form Number Description File FormatLanguage
FIN524 Discount Health Care Program Operator Marketers Form
Use this form to provide a list of the marketers authorized to sell or distribute the program operator's program under the program operator's name, and a list of the marketing entities authorized to private label the program operator's programs.
EXCEL
FIN525 Discount Health Care Program Operator Surety Bond Form
Use this form of an original surety bond in the principal amount of $50,000 to show Financial Responsibility.
PDFEnglish
FIN526 Discount Health Care Program Operator Biographical Certificate Form
Form for Discount Health Care Program Operator Biographical Certificates. Follow the instructions within the form for completion.
PDFEnglish
FIN527 Discount Health Care Program Operator Registration Form
Form for Registration as a Discount Health Care Program Operator.
PDFEnglish

 

Captive Management Company Forms
TDI Form Number Description File FormatLanguage
FIN548 Captive Management Company Biographical Certificate Form
Form used for Captive Management Company's Biographical Certificate information. Follow the instructions within the form.
PDFEnglish
FIN549 Captive Management Company Registration Form
Form used for Captive Management Company Registration information. Follow the instructions within the form.
PDFEnglish

 

Information Update Forms
TDI Form Number Description File FormatLanguage
FIN530 Request for Letter(s) of Certification
Rev 3/2012
PDFEnglish
FIN531 Biographical Form
Entity/Change of Control
PDFEnglish
FIN533 Licensee Name/Address Change Request Form
PDFEnglish
LHL203 Registration of Assumed Name/Branch Locations/Entity Name Change
Commonly known as form LDTL
PDFEnglish
LHL208 ISR Transfer/Cancel
Employment Form
PDFEnglish
LHL388 Branch Office Address Change Request
PDFEnglish
LHL 430 Medicare Plan Marketing Report
EXCEL
NIPR Electronic Address Change Request for Agents and Adjusters - fill in and send on-line.
(For in-state address changes, an agent or adjuster can use this tool to simultaneously provide an address change notification to all state insurance departments where the agent or adjuster is licensed. There is no charge for the service.)
Web Enabled

 

Navigator Registration Forms
TDI Form Number Description File FormatLanguage
FIN573 Application / Renewal Form for Navigator Individual Registration
PDFEnglish
FIN574 Application / Renewal form for Navigator Entity Registration
PDFEnglish
FIN575 Navigator Surety Bond Form
PDFEnglish
FIN576 Navigator Entity Designated Responsible Person Biographical Certificate
PDFEnglish

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