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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
FastForm for fingerprint card
Fingerprint Card Scan Authorization Form to submit with fingerprint card
Rev 10/2015
PDF English
FastForm for electronic fingerprint appointment
FastPass Form for electronic fingerprint appointment
Rev 10/2015
PDF English
Officers and Directors Page
Complete Listing of all Current Officers and Directors
PDF English
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
PDF English
Administrator Biographical Affidavit
Form to be completed by each executive officer or other comparable responsible person (i.e. officer, director, partner, sole proprietor, or owner) (also known as form LHL081)
PDF English
Service of Process Form for Administrators
Form required to be submitted by all foreign or alien applicants, appointing the commissioner of insurance as its true and lawful attorney for service of process. (Also known as form LHL082)
PDF English
Annual Report for Administrators
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
Annual Report for Insurers and HMOs Subject to 28 TAC 7.1605
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
Annual Report Exhibits A-E
Form to be submitted with annual report, summarizes business administered in Texas during preceding year
EXCEL English
Application for Certificate of Authority as an Administrator
Form and instructions for entities wishing to obtain a certificate of authority to do business as an Administrator in Texas, under TIC Chapter 4151
PDF English
Certification of Financial Statement for Administrators
Form to be executed by authorized officer, attesting that the unaudited financial statement is a full and true statement, etc.
PDF English
Surrender Affidavit for Third Party Administrator Certificate of Authority
Affidavit surrendering the Certificate of Authority for a Third Party Administrator
PDF English
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
Checklist for TPA Name Change
Checklist to be submitted by a Third-Party Administrator to effect a name change. (also known as form LHL177)
PDF English
Instructions for Filing the Third-Party Administrators (TPA) Annual Report
Instructions for filing the Third-Party Administrators Annual Report (FIN486 and FIN487)
PDF English
Request for Certified Copy of Third-Party Administrator Certificate of Authority to do Business in Texas
Renewal of TPA license, in most states, requires that the TPA submit a current copy of their license from their home state, or certificate of good standing. Complete this form to request certified copies.
PDF English
Notice of Change of Control
Third-Party Administrator's authorized officer to complete this form for a change of control
PDF English
TPA Check Transmittal Form
Third-Party Administrators to use this transmittal form when sending checks without documents. If sending documents, use the appropriate form.
PDF English
Fingerprinting Requirements
Instructions for Third-Party Administrators when submitting documents required for background checks
PDF English

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Translation by WorldLingo

Translation by WorldLingo