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Third Party Administrator - Company Licensing and Registration

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

Third Party Administrator - Company Licensing and Registration
TDI Form Number Description File FormatLanguage
FIN306
Officers and Directors Page
Complete Listing of all Current Officers and Directors
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
FIN484
Administrator Biographical Affidavit
TPA form to be completed by each principal (i.e. officer, director, partner, sole proprietor, or owner) (also known as form LHL081)
PDF English
FIN485
Service of Process Form for Administrators
TPA form required from all foreign or alien applicants, appointing the commissioner of insurance as attorney for service of process. (Also known as form LHL082)
PDF English
FIN486
Annual Report Form for Administrators
TPA Form with required documents to be submitted annually by all Third-Party Administrators holding a certificate of authority under TIC Chapter 4151; due no later than June 30th, with $200 Annual Report filing fee.
PDF English
FIN487
Annual Report for Insurers and HMOs Subject to 28 TAC 7.1605
TPA Form with required documents to be submitted annually by all Insurers and HMOs, subject to 28 TAC 7.1605; due no later than June 30th, with $200 Annual Report filing fee.
PDF English
FIN488
Annual Report Exhibits A-E
Form to be submitted with annual report, summarizes business administered in Texas during preceding year
EXCEL English
FIN489
Application for Certificate of Authority
Form and instructions for entities wishing to obtain a certificate of authority to do business as an Administrator (TPA) in Texas, under TIC Chapter 4151
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
FIN497
Surrender Affidavit for Third Party Administrator Certificate of Authority
Affidavit surrendering the Certificate of Authority for a Third Party Administrator
PDF English
FIN498
Third-Party Administrators Notice of Change of Address and/or Contact form
TPA to complete this form notifying the department of a change of address or other contact information
PDF English
FIN499
Checklist for Administrator (TPA) Name Change
Checklist to be submitted by a Third-Party Administrator to effect a name change.
PDF English
FIN500
Instructions for Filing the Third-Party Administrators Annual Report
Instructions for filing the Third-Party Administrators Annual Report (FIN486 and FIN487)
PDF English
FIN502
Notice of Change of Control
Third-Party Administrator's authorized officer to complete this form for a change of control
PDF English

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