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Company Licensing and Registration Forms and Checklists

Financial - Company Licensing and Registration Office

Company Licensing and Registration Forms and Checklists
TDI Form Number Description File FormatLanguage
FIN179
Guidelines for the formation of a Texas Captive Insurance Company
Guidelines for the formation of a Texas Captive Insurance Company
PDF English
FIN180
Certificate of Authority Application for a Captive Insurance Company
Certificate of Authority Application for a Captive Insurance Company, either a Texas start up or a company wishing to redomesticate to Texas
PDF English
FIN181
Biographical Affidavit for Captive Insurance Company
Biographical Affidavit form for individuals that oversee management of the Captive Insurance Company
PDF English
FIN182
Financial Projections for Captive Insurance Company
Financial Projections Excel Workbook for Captive Insurance Company
EXCEL English
FIN183
Guidelines for captive insurance company who wishes to relocate to Texas, including optional pre-filing process.
Redomestication Guidelines for Captive Insurance Companies
PDF English
FIN184
Appointment of Agent for Service of Process for a Captive Insurance Company
Notarized form appointing an agent for service of process for a captive insurance company
PDF English
FIN185
Moving a Captive Insurance Company's Books and Records Out of the State of Texas Under Texas Insurance Code, Section 803
Form and requirements for a captive insurance company wishing to move its books, records, accounts, and/or principle office(s) outside the state of Texas
PDF English
FIN186
Captive Insurance Company Officers' Certification and Attestation Certificate of Filing
Certification by a Captive Insurance Company's Officers in regards to true and accurate information submitted with application
PDF English
FIN300
Company Name Application
Application to reserve a company name
PDF English
FIN302
HMO Application for Certificate of Authority
Application for an HMO to do business in the state of Texas
PDF English
FIN306
Officers and Directors Page
Complete Listing of all Current Officers and Directors
PDF English
FIN307
Attorney-in-Fact and Underwriters Page
Lists the Attorney-in-Fact and Underwriters of Lloyds and Reciprocals
PDF English
FIN310
Application For A License As An Advisory Organization
Submit application to be licensed as an Advisory Organization
PDF English
FIN311
Biographical Affidavit
Biographical Affidavit form to be completed by certain officers and directors of insurance companies; compliance with statute
PDF English
FIN312
Attorney for Service form
Attorney for Service form
PDF English
FIN321
Company Licensing Fee Transmittal Form
Company Licensing and Registration Fee Transmittal Form to be submitted with filings.
PDF English
FIN322
Articles of Incorporation for a Texas Domestic P&C Company
Submitted as Articles of Incorporation for a Texas Domestic Property and Casualty Company
PDF English
FIN323
Articles of Incorporation for a Texas Domestic Life, Health and Accident Company
Submitted as Articles of Incorporation for a Texas Domestic Life, Health and Accident Company
PDF English
FIN324
Biographical Affidavit Update
submitted as notification of changes to biographical affidavit
PDF English
FIN325
State of Texas Statement of Retaliatory Fees and Requirements
Requirements for insurers, including Capital and Surplus Requirements; Fees; Deposit and Bonds, Premium Tax Requirements, and Additional Taxes
PDF English
FIN332
Articles of Incorporation Amendments for Texas Stock Property and Casualty or Life, Health and Accident Insurance Companies
Amendments to Articles of Incorporation for Texas Domestic Company
PDF English
FIN341
Merger Checklist
Checklist for filing a merger between two stock insurance companies where at least one of the companies is domiciled in Texas
PDF English
FIN345
Total and Partial Assumption Reinsurance for Domestic Companies
Checklist for Total and Partial Assumption Reinsurance Agreements involving at least one Texas domestic insurance company
PDF English
FIN346
Checklist for Total and Partial Reinsurance Agreements Involving Foreign Insurance Companies
Checklist for Total or Partial Assumption Reinsurance Agreements involving two foreign insurance companies
PDF English
FIN349
Withdrawal Checklist
Filing instruction for an insurer wanting to withdraw or cease writing a line or lines of insurance in the state of Texas
PDF English
FIN350
Guidelines to Re-enter Texas Market Subsequent to Withdrawal
Filing instruction for insurance companies wishing to re-enter the Texas insurance market subsequent to filing a withdrawal plan
PDF English
FIN351
Voluntary Dissolution Checklist
Instructions for a Texas-Domestic Company wanting to Dissolve and Cancel its Certificate of Authority
PDF English
FIN352
CCRC Biographical Affidavit Requirements
Biographical afffidavit requirements for Continuing Care Retirement Communities (CCRCs)
PDF English
FIN353
Biographical Affidavit and Fingerprint Requirements for Texas-Domestic Insurers
Requirements and instructions for submitting biographical affidavits and fingerprints for Texas-domestic insurers
PDF English
FIN354
Biographical Affidavit and Fingerprint Requirements for Foreign Insurers
Instructions and requirements for submitting biographical affidavit and fingerprints for foreign insurers
PDF English
FIN355
Biographical Affidavit and Fingerprint Requirements for Health Maintenance Organizations (HMOs)
Instructions and requirements for submitting biographical affidavit and fingerprints for Health Maintenance Organizations (HMOs)
PDF English
FIN356
Biographical Affidavit and Fingerprint Requirements for Texas Lloyds and Reciprocal Insurers
Instructions and requirements for submitting biographical affidavit and fingerprints for Texas Lloyds and Reciprocal insurers
PDF English
FIN357
HMO Certificate of Authority Application Checklist
Filing instructions for an entity wishing to do business as a Health Maintenance Organization (HMO) in Texas
PDF English
FIN358
HMO DBA Filing Checklist
Filing instructions relating to an HMO's DBA, Assumed Name, Trade Mark, Service Marks and Logos
PDF English
FIN359
HMO Home Office Change Checklist
Filing instruction related to a Health Maintenance Organization's subsequent filing for a home office change
PDF English
FIN360
HMO Name Change Checklist
Instructions related to a Health Maintenance Organization's subsequent filing for a name change
PDF English
FIN361
HMO Service Area Expansion
Filing instructions for a Health Maintenance Organization wishing to provide HMO coverage in additional counties
PDF English
FIN363
HMO Merger Checklist
Checklist and instructions for a Health Maintenance Organization's merger filing
PDF English
FIN364
Cancellation of HMO Certificate of Authority
Instructions for a Health Maintenance Organization wishing to cancel its HMO certificate of authority to transact business in Texas
PDF English
FIN365
HMO Withdrawal Guidelines
Guidelines for a Health Maintenance Organization to file a plan of orderly withdrawal before the HMO undertakes total or substantial withdrawal.
PDF English
FIN367
Reciprocal or Inter-Insurance Exchanges (Form A-212)
Application to transact business as a reciprocal or inter-insurance exchange
PDF English
FIN368
Instructions for the Original Incorporation of Texas Lloyds Company
Instructions for the original incorporation of a Lloyds Company
PDF English
FIN369
Form A-211 (Lloyds)
Form for Lloyds companies to complete for a new or amended Certificate of Authority
PDF English
FIN370
Charter Amendment Guidelines for a Lloyds Plan
Instructions for Lloyds amendments, including Underwriter Substitution, Attorney-in-Fact Change, Name Change or Home Office Change, or Increase in Guaranty Fund or Surplus Contribution
PDF English
FIN371
Attorney-in-Fact Change Checklist for Reciprocals
Attorney-in-fact Change Checklist for Reciprocals (only)
PDF English
FIN372
Conversion of Lloyds to Stock P&C Insurer
Filing instructions for a Lloyds insurer to convert to a stock property and casualty insurer
PDF English
FIN373
Instructions for Certificate of Authority for Multiple Employer Welfare Arrangement
Filing instructions for preparing the application to become licensed as a Multiple Employer Welfare Arrangement (MEWA)
PDF English
FIN374
MEWA Application to Do Business
Application form to do business as a Multiple Employer Welfare Arrangement (MEWA)
PDF English
FIN375
Application for Initial Certificate of Authority (MEWA)
Multiple Employer Welfare Arrangement (MEWA) application for a temporary, or initial certificate of authority
PDF English
FIN376
MEWA Officers, Directors, and Trustees Page
Listing of all officers, directors, and trustees associated with the Multiple Employer Welfare Arrangement (MEWA)
PDF English
FIN377
Service of Process (MEWA)
Multiple Employer Welfare Arrangement (MEWA) Service of Process form
PDF English
FIN378
MEWA Annual Filing Checklist
Instructions for submitting annual filing for a Multiple Employer Welfare Arrangement (MEWA)
PDF English
FIN381
CCRC Filing Requirements for Certificate of Authority
Instructions for an entity wishing to operate as a Continuing Care Retirement Community (CCRC) in Texas
PDF English
FIN382
CCRC 1 - Application for Certificate of Authority to do Business in Texas
Continuing Care Retirement Community (CCRC) application for Certificate of Authority to do business in Texas, CCRC From #1
PDF English
FIN383
CCRC 2 - Application for Approval by the Commissioner for Release of Loan Reserve Fund Escrow Account Amounts In Excess of that Allowed by Rule
Application for Commissioner's approval to release loan reserve fund escrow amounts in excess of that allowed by rule (CCRC Form #2)
PDF English
FIN384
CCRC 3 - Officers and Directors Page
Continuing Care Retirement Community (CCRC) listing of all associated officers and directors, CCRC Form #3
PDF English
FIN385
CCRC 4 - Biographical Data Form for a For-Profit CCRC
Continuing Care Retirement Community (CCRC) biographical data form to be completed by any person serving as a board member for a for-profit CCRC, CCRC Form #4
PDF English
FIN386
CCRC 4A - CCRC Biographical Affidavit for a Not-For-Profit CCRC
Continuing Care Retirement Community (CCRC) biographical data form to be completed by any person serving as a board member for a Not-for-Profit CCRC, CCRC Form #4a
PDF English
FIN387
CCRC 5 - Acknowledgement of Delivery of Disclosure Statement
Continuing Care Retirement Community (CCRC) resident's acknowledgement of delivery of Disclosure Statement, CCRC Form #5
PDF English
FIN388
CCRC 6 - Format for Disclosure Statement
Continuing Care Retirement Community (CCRC) detailed instructions and format for submitting Disclosure Statement, CCRC Form #6
PDF English
FIN389
CCRC Form #6A - CCRC Instructions for Preparation of Disclosure Statement
Continuing Care Retirement Community (CCRC) instructions for preparing Disclosure Statement filing, CCRC Form #6a
PDF English
FIN390
CCRC 7 - Change of Control Statement
Continuing Care Retirement Community (CCRC) instructions including content and format in preparing statement regarding a change of control, CCRC Form #7
PDF English
FIN391
CCRC 8 - Certification of Changes to Disclosure Statement
Continuing Care Retirement Community (CCRC) certification of changes made to the Disclosure Statement, CCRC Form #8
PDF English
FIN392
CCRC 9 - Notice of Request to Release Entrance Fee Escrow Funds
Continuing Care Retirement Community (CCRC) written notice of request to release entrance fee escrow funds, CCRC Form #9
PDF English
FIN393
CCRC 10 - Notice of Request to Release Funds from the Reserve Fund Escrow Account
Continuing Care Retirement Community (CCRC) written notice of request to release funds from the reserve funds escrow account, CCRC Form #10
PDF English
FIN394
CCRC 11 - Notice by Provider of Re-Payment of Previously Released Funds to the Reserve Fund Escrow Account
Continuing Care Retirement Community (CCRC) Provider's affidavit for repayment of previously released funds to the Reserve Fund Escrow Account, CCRC Form #11
PDF English
FIN395
CCRC 12 - Escrow Agent's Affidavit of Re-payment of Previously Released Funds to the Reserve Fund Escrow Account
Continuing Care Retirement Community (CCRC) escrow agent's affidavit for repayment of previously released funds to the Reserve Fund Escrow Account, CCRC Form #12
PDF English
FIN396
CCRC 13 - Notice of Lien
Continuing Care Retirement Community (CCRC) written notice of lien, CCRC Form #13
PDF English
FIN397
CCRC 14 - Calculations Concerning Conditions
Continuing Care Retirement Community (CCRC) calculations concerning conditions, CCRC Form #14
PDF English
FIN398
CCRC Name Change Checklist
Continuing Care Retirement Community (CCRC) charter amendment checklist to effect a name change
PDF English
FIN403
Continuing Care Retirement Community (CCRC) Release of Funds from Escrow
Continuing Care Retirement Community (CCRC) instructions relating to written notice for a request of release of funds from the entrance fee escrow
PDF English
FIN405
Company Licensing and Registration Open Records Request
Open Records Request form for the Company Licensing and Registration Office
PDF English
FIN406
Statutory Deposit Fee Transmittal Form
Fee transmittal form submitted with statutory deposit filings
PDF English
FIN407
Statutory Deposit Transaction Form
Statutory Deposit Transaction Form is submitted when a securities is deposited or withdrawn.
PDF English
FIN409
Texas PEO Quarterly Report
Quarterly report filed for PEO self-funded employee health benefit plans.
EXCEL English
FIN410
Texas PEO Annual Report
Annual financial report filed by PEO self-funded health benefit plans.
EXCEL English
FIN411
Financial Projections for Self-Funded PEO Plans
Financial projections to be submitted for a PEO self-funded health benefit plan.
EXCEL English
FIN412
Professional Employer Organization Application for a Certificate of Approval to Sponsor a Client Employer Health Benefit Plan
Certificate of approval application and checklist for a PEO sponsored Client Employer Health Benefit Plan
PDF English
FIN414
Notification to the Commissioner for Registration as a Purchasing Group - Form PG1
Form PG1 - used for the initial registration of a group that intends to do business in Texas
PDF English
FIN415
Annual Agent Report for Risk Retention and Purchasing Groups - Form PG3
Form PG3 required to be filed by any agent for a purchasing group and shown on Form PG1 or Form PG1R
PDF English
FIN416
Appointment of Commissioner as Agent - Form RRG/PG C1
Form RRG/PG PC1 required for all purchasing groups. Notarized form appoints Commissioner of Insurance as agent for the purchasing group.
PDF English
FIN417
Renewal/Amendment of Purchasing Group Registration - Form PG1R
Form PG1R - Form (notarized) and instructions used to report changes to the original registration and for annual renewal of Purchasing Groups, due by July 1.
PDF English
FIN419
Registration of a Foreign/Alien Risk Retention Group - Form RRG-A-122
Form RRG-A-122 required for initial registration and renewal of a Risk Retention Group that intends to do business in Texas.
PDF English
FIN420
Risk Retention Group Initial and Annual Filing Requirements Checklist
Checklist provided to Risk Retention Groups to ensure all required documents are completed and submitted within required deadlines.
PDF English
FIN422
Foreign (U.S. domiciled) Surplus Lines Insurers Filing Requirements/Checklist
Instructions/Checklist for foreign (U.S. domiciled) Surplus Lines insurers that wish to obtain/maintain SL eligibility. See FIN421 for Memorandum to be utilized in conjunction with FIN422.
PDF English
FIN423
Alien non US domiciled Surplus Lines Insurers Filing Requirements Checklist
Instructions Checklist for alien non US domiciled Surplus Lines insurers that wish to obtain-maintain SL eligibility. See Form FIN421 for Memorandum to be utilized in conjunction with this Form FIN423. These requirements apply only to Alien Surplus
PDF English
FIN426
Form R-4, Accredited/Trusteed Reinsurer Checklist
See FIN425 for memo with further instructions. Accredited Reinsurers to submit this form with initial and annual filing.
PDF English
FIN427
Form R-1, Submission for Reinsurance Accreditation
See FIN425 for memo with further instructions.
PDF English
FIN428
Form R-3, Certificate of Assuming Insurer
Form R-3 (notarized form) Designates Commissioner of Insurance as Attorney for Service; submits to the COI to examine its books and records; submits to the jurisdiction of any court of competent jurisdiction in Texas for adjudication of any issues.
PDF English
FIN429
Accredited/Trusteed Reinsurer Business Plan Outline
Guide to key elements that might be included in a 3-year business plan for Accredited/Trusteed Reinsurers.
PDF English
FIN430
License Application for a Life Settlement Provider or Broker
Original application for licensure of a life settlement broker or provider, which includes checklists for filing requirements of the initial application
PDF English
FIN431
Application for Renewal, Surrender, or Change of Information for a Life Settlement Provider or Broker
Application for renewal of a broker or provider license or to report change of information of an existing life settlement broker or provider
PDF English
FIN432
Life Agent Notification to TDI to act as a Life Settlement Broker
Required for applicants who have held a resident Texas life or life and health license for at least one year
PDF English
FIN434
Biographical Affidavit for Life Settlement Providers or Brokers
Biographical affidavit. Must be completed by all individuals specified in the instructions of FIN430 and FIN431, as adopted by rule.
PDF English
FIN435
Initial Statutory Deposit Checklist
Checklist for an insurance company to initially place security funds on deposit
PDF English
FIN436
Name Change for Securities on Deposit Checklist
Checklist outlining documents required for an insurance company to change the name for which securities are held
PDF English
FIN437
Substituting Securities on Deposit Checklist
Checklist outlining documents required for an insurance company to substitute securities held on deposit
PDF English
FIN438
Withdrawal of Statutory Deposit Checklist
Instructions outlining documents required for an insurance company to withdraw securities on deposit, due to a reduction, dissolution, merger, or cancellation of company's Certificate of Authority
PDF English
FIN440
Instructions for Completing Securities Deposited Form 120
PDF English
FIN441
Securities Deposit Form 120 (FIN 441)
Securities Deposit Form 120, to be used by insurance companies. Refer to FIN440 for instructions in completing this form.
PDF English
FIN444
Instructions for Completing Securities Withdrawn Form 121
Instructions for completing securities withdrawn Form 121
PDF English
FIN445
Securities Withdrawn Form 121 (FIN445)
Securities Withdrawn Form 121, to be used by insurance companies. Refer to FIN444 for instructions in completing this form.
PDF English
FIN450
Joint Control Agreement
Form to be executed by Lloyds plan when placing required net assets as required by statute
PDF English
FIN451
Instructions for HMOs Placing Securities on Deposit
Instructions for Health Maintenance Organizations when placing securities on deposit
PDF English
FIN452
HMO Pledge Letter Example
Template for Health Maintenance Organizations to use when pledging assets, as required by statute
PDF English
FIN453
Declaration of Trust
Form to be executed for securities held on deposit
PDF English
FIN482
Notification that an Insurer or HMO will be acting as an Administrator
Form notifying TDI than an Insurer or HMO will be acting as an Administrator (TPA)
PDF English
FIN490
Certification of Financial Statement Form for Administrators
Form to be executed by authorized officer, attesting that the unaudited financial statement is a full and true statement of assets, etc.
PDF English
FIN590
Financial Analysis Fee Transmittal Form
for MEWAs and CCRCs
PDF English
TPA Annual Report Workbook
TPA Annual Report Workbook
Compilation of TPA Annual Report Forms FIN486-488, which can be submitted to meet TPA Annual Report requirements.
EXCEL English

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