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Texas Department of Insurance
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Workers' Compensation Self-Insurance Groups

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TDI Form Number Description File Format Language
FIN404

Workers Compensation Group Self-Insurance Coverage Acknowledgement of Indemnity Agreement

Workers' Compensation Self-Insurance Group (SIG) coverage acknowledgement of indemnity agreement; employer's joint and several liability agreement

PDF English
FIN464

Workers' Compensation Self-Insured Group (SIG) Administrator or Service Company Bond

Format Instructions

PDF English
FIN465

Workers Compensation Self-Insurance Group Application

Application for Certificate of Approval to Conduct Workers Compensation Self-Insurance Group (SIG) Business

PDF English
FIN466

Workers Compensation Self-Insurance Group (SIG) Application Checklist

Application checklist for workers compensation Self-Insurance Groups (SIG)

PDF English
FIN467

Workers Compensation Self-Insurance Group (SIG) Employer Membership Form

Employer membership form for workers compensation Self-Insurance Groups

PDF English
FIN468

Workers Compensation Self-Insurance Group (SIG) Notification Form

Mandatory notification to the commissioner of insurance regarding any one of a variety of possible changes that a workers compensation Self-Insurance Group (SIG) makes

PDF English
FIN469

Workers Compensation Self-Insurance Group (SIG) Termination of Certificate of Approval Checklist

Checklist for a workers compensation Self-Insurance Group (SIG) to apply for termination of its certificate of approval

PDF English
FIN470

Workers Compensation Self-Insurance Group (SIG) Merger Checklist

Checklist for a workers compensation Self-Insurance Group (SIG) to merge with another SIG engaged in the same or similar type of business

PDF English
FIN471

Workers Compensation Self-Insurance Group (SIG) 5% Investments

Instruction for a workers compensation Self-Insurance Group (SIG) regarding authorized investments for meeting minimum capital and surplus and reserves

PDF English
FIN472

Workers Compensation Self-Insurance Group (SIG) Hazardous Financial Condition Notice

Instructions and checklist for a workers compensation Self-Insurance Group (SIG) should it become insolvent or discover a hazardous financial condition

PDF English
FIN473

Workers Compensation Self-Insurance Group (SIG) Changes to Service Company Agreements Checklist

Checklist for a workers compensation Self-Insurance Group (SIG) if there are any changes to agreements or new agreements are entered into with an administrator/service company

PDF English
FIN474

Workers Compensation Self-Insurance Group (SIG) Change in Security for Incurred Liabilities Form

Security deposit instructions for a workers compensation Self-Insurance Group (SIG)

PDF English
FIN475

Workers Compensation Self-Insurance Group (SIG) Change in Performance or Fidelity Bond Checklist

Checklist for a workers compensation Self-Insurance Group (SIG) for a change in performance or fidelity bond

PDF English
FIN476

Workers Compensation Self Insurance Group Changes to Corporate Governance Documents Checklist

Checklist for a workers compensation Self Insurance Group to make a change to its corporate governance documents, including By Laws, Articles of Association, Incorporation, or other documentation used to verify the existence of the SIG and or Trust

PDF English
FIN477

Workers Compensation Self-Insurance Group (SIG) Excess Insurance Checklist

Checklist for a workers compensation Self-Insurance Group (SIG) to establish excess insurance for losses

PDF English
FIN478

Workers Compensation Self-Insurance Group (SIG) Financial Pro Forma

Financial Pro Forma for a workers compensation Self-Insurance Group (SIG)

PDF English
FIN479

Workers Compensation Self-Insurance Group (SIG) Movement of Books and Records Checklist

Checklist for a workers compensation Self-Insurance Group (SIG) to request to move its books and records out of Texas

PDF English
FIN480

Workers Compensation Self-Insurance Group (SIG) Increase or Decrease in Membership Checklist

Checklist for a workers compensation Self-Insurance Group (SIG) if there is an increase or decrease in membership

PDF English

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