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PEO Self-Funded Health Plans

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

PEO Self-Funded Health Plans
TDI Form Number Description File FormatLanguage
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
FIN405
Company Licensing and Registration Open Records Request
Open Records Request form for the Company Licensing and Registration Office
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Statutory Deposit Transaction Form is submitted when a securities is deposited or withdrawn.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
FIN453
Declaration of Trust
Form to be executed for securities held on deposit
PDF English

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