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HMO Transactions Forms and Checklists - Company Licensing and Registration

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For more information regarding any of the topics below, go to the Company Licensing and Registration home page.

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TDI Form Number Description File Format Language
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
FIN311

Biographical Affidavit

Biographical Affidavit form to be completed by certain officers and directors of insurance companies; compliance with statute

PDF English
FIN321

Company Licensing Fee Transmittal Form

Company Licensing and Registration Fee Transmittal Form to be submitted with filings.

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
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
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
FIN407

Statutory Deposit Transaction Form

Statutory Deposit Transaction Form is submitted when a securities is deposited or withdrawn.

PDF English
FIN435

Checklist for Placing an Initial Statutory Deposit

Checklist for an insurance company to initially place security funds on deposit.

PDF English
FIN436

Checklist for a Name Change or Merger of Securities on Deposit

Checklist outlining documents required for an insurance company to change the name for which securities are held.

PDF English
FIN437

Checklist for Substituting Securities on Deposit

Checklist outlining documents required for an insurance company to substitute securities held on deposit.

PDF English
FIN438

Checklist for Withdrawal of Statutory Deposit

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
FIN453

Declaration of Trust

Form to be executed for securities held on deposit.

PDF English

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