• Increase Text Icon
  • Decrease Text Icon
  • Email Icon
  • Printer Icon
You are here: 

Third Party Administrator - Company Licensing and Registration

This is one of several pages linking to a central repository of forms used by TDI customers. Use the search or Forms by Type links on the Forms Home Page or scan through our form listings.

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


 

TPA Application Forms
TDI Form NumberDescriptionFile FormatLanguage
FastForm for electronic fingerprint appointment FastPass Form for electronic fingerprint appointment
Rev 1/2013
PDFEnglish
FastForm for fingerprint card Fingerprint Card Scan Authorization Form to submit with fingerprint card
Rev 1/2013
PDFEnglish
TPA Application Forms
TDI Form NumberDescriptionFile FormatLanguage
FIN306 Officers and Directors Page
Complete Listing of all Current Officers and Directors
PDFEnglish
FIN484 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)
PDFEnglish
FIN485 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)
PDFEnglish
FIN489 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
PDFEnglish
FIN490 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.
PDFEnglish
FIN498 Third-Party Adminstrators 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
PDFEnglish
FIN499 Checklist for TPA Name Change
Checklist to be submitted by a Third-Party Administrator to effect a name change. (also known as form LHL177)
PDFEnglish
FIN500 Instructions for Filing the Third-Party Administrators (TPA) Annual Report
Instructions for filing the Third-Party Administrators Annual Report (FIN486 and FIN487)
PDFEnglish
FIN501 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.
PDFEnglish
FIN502 Notice of Change of Control
Third-Party Administrator's authorized officer to complete this form for a change of control
PDFEnglish
FIN503 Check Transmittal Form
Third-Party Administrators to use this transmittal form when sending checks without documents. If sending documents, use the appropriate form.
PDFEnglish
FIN504 Fingerprinting Requirements
Instructions for Third-Party Administrators when submitting documents required for background checks
PDFEnglish

 

TPA Annual Report Forms
TDI Form NumberDescriptionFile FormatLanguage
FIN306 Officers and Directors Page
Complete Listing of all Current Officers and Directors
PDFEnglish
FIN486 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.
PDFEnglish
FIN487 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.
PDFEnglish
FIN488 Annual Report Exhibits A-E
Form to be submitted with annual report, summarizes business administered in Texas during preceding year
EXCEL
FIN490 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.
PDFEnglish

For more information contact:



 

Contact Information and Other Helpful Links

Translation by WorldLingo


Translation by WorldLingo