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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.

HMO Transactions Forms and Checklists - Company Licensing and Registration
TDI Form Number Description File FormatLanguage
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
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
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
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
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

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