Texas Department of Insurance

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Listing of All Texas Department of Insurance Forms

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.

Forms - NAIC 

TDI Forms Listing
TDI Form NumberDescriptionFile FormatLanguage
AS004 Accounting Texas Overhead Assessment
Accounting form for domestic companies to report if they have pension plan contracts that are exempt from OA		 PDFEnglish
AS044 Insurance Agent /Agency Order Form
Insurance Agent/Agency and Insurance Companies Order Form		 PDFEnglish
MentorApp Historically Underutilized Business
Mentor - Protégé Program		 WORDEnglish
CP003 TDI Speakers Bureau Request Form
TDI Speakers Bureau Request Form		 PDFEnglish
CP012 Complaint Form
Complaint Form - English		 PDFEnglish
CP012 Complaint Form
Complaint Form - English		 RTFEnglish
CP012 Physician and Health Care Provider Information
Attachment A - Physician and Health Care Provider Information		 RTFEnglish
CP012 Spanish Complaint Form
Complaint Form - En Español		 PDFSpanish
CP012 Spanish Complaint Form
Complaint Form - En Español		 RTFSpanish
CP021 Certificate of Compliance of Advertising
Advertising Compliance Form		 PDFEnglish
CP021 Certificate of Compliance of Advertising
Advertising Compliance Form		 WORDEnglish
CP024 Advertising Transmittal Form
Transmittal Form for Advertising Filings		 PDFEnglish
CP026 CHAP Speakers Bureau Request Form
CHAP Speakers Bureau Request Form		 PDFEnglish
LHL619 Health Insurance Mediation Request Form
Request health insurance mediation 		PDFEnglish
DWC001 Employer's First Report of Injury or Illness
(Rev. 10/05) This form is submitted to by carrier to DWC (with cover sheet and instructions)		 PDFEnglish
DWC001S Employer's First Report of Injury or Illness (for state employees)
(Rev. 10/05)		 PDFEnglish
DWC002 Employer's Report for Reimbursement of Voluntary Payment
(Rev. 10/05)		 PDFEnglish
DWC003 Employer's Wage Statement
(Rev. 10/05)		 PDFEnglish
DWC003ME Employee's Multiple Employment Wage Statement
(Rev. 10/05)		 PDFEnglish
DWC003MES Declaración de Salario de Múltiples Trabajos del Empleado
(Rev. 10/05)		 PDFSpanish
DWC003S Declaración de Salario del Empleador
(Rev. 10/05)		 PDFSpanish
DWC003SD Employer's Wage Statement for School Districts
(Rev. 10/05)		 PDFEnglish
DWC003SDS Declaración de Salario Para Escuelas de Distrito
(Rev. 10/05)		 PDFSpanish
DWC004 Employer's Contest of Compensability
(Rev. 11/08)		 PDFEnglish
DWC005 Employer Notice of No Coverage or Termination of Coverage
(Rev. 11/10)		 PDFEnglish
DWC005s Notificación del Empleador por No Cobertura o Anulación de la Cobertura
(Rev. 11/10)		 PDFSpanish
DWC006 Supplemental Report of Injury
(Rev. 10/05)		 PDFEnglish
DWC007 Non-Covered Employer's Report of Occupational Injury or Illness
(Rev. 10/05)		 PDFEnglish
DWC007SUP Supplement DWC 7, Non-Covered Employer's Report of Occupational Injury or Illness
(Rev. 10/05)		 PDFEnglish
DWC008 Return-to-Work Reimbursement Program for Employers
(Rev. 04/10)		 PDFEnglish
DWC008 Return-to-Work Reimbursement Program for Employers
(Rev. 04/10)		 WORDEnglish
DWC020 Insurance Carrier's Notice of Coverage/Cancellation/Non-Renewal of Coverage
(Rev. 10/05)		 PDFEnglish
DWC020A Correction/Revision/Endorsement to Existing Policy
(Rev. 10/05)		 PDFEnglish
DWC020SI Self-Insured Governmental Entity Proof of Coverage
(Rev. 10/06)		 PDFEnglish
DWC022 Required Medical Examination (RME) - Request for Agreement / Request for Order
Rev. 7/11		 PDFEnglish
DWC022S Examen Médico Requerido (Required Medical Examination –RME, por su nombre y siglas en inglés) – Solicitud para un Acuerdo / Solicitud para una Orden
Rev. 7/11		 PDFSpanish
DWC024 Benefit Dispute Agreement
(Rev. 10/05)		 PDFEnglish
DWC024s Acuerdo para Disputa de Beneficios
(Rev. 07/08)		 PDFSpanish
DWC025 Benefit Dispute Settlement
(Rev. 10/05)		 PDFEnglish
DWC025s Acuerdo por Disputa de Beneficios
(Rev. 07/08)		 PDFSpanish
DWC026 Request for Reimbursement of Payment Made by Health Care Insurer
(Rev. 05/11)		 PDFEnglish
DWC027 Designation of Insurance Carrier’s Austin Representative
(Rev. 12/11)		 PDFEnglish
DWC030 Austin Representative’s Authorized Designees
(Rev. 12/11)		 PDFEnglish
DWC031 Application for Division Approval of Change in the Payment Period and/or Purchase of an Annuity for Death Benefits
(Rev. 10/05)		 PDFEnglish
DWC031s Solicitud para Obtener Aprobación por Parte de la División para un Cambio en el Periodo de Pago y/o Compra de una Pensión Para los Beneficios por Causa de Muerte
(Rev. 10/05)		 PDFSpanish
DWC032 Request for Designated Doctor Examination
(Rev. 12/10)		 PDFEnglish
DWC032S Solicitud para Obtener un Examen por Parte de un Médico Designado
(Rev. 12/10)		 PDFSpanish
DWC033 Carrier's Request for Reduction of Income Benefits Due to Contribution
(Rev. 10/05)		 PDFEnglish
DWC035 Application for Division Approval of the Purchase of an Annuity for Lifetime Income Benefits
(Rev. 10/05)		 PDFEnglish
DWC041 Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease
(Rev. 3/07)		 WORDEnglish
DWC041 Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease
(Rev. 3/07)		 PDFEnglish
DWC041S Reclamo del Empleado para Compensación por una Lesión Relacionada con el Trabajo o Enfermedad Ocupacional
(Rev. 3/07)		 PDFSpanish
DWC041S Reclamo del Empleado para Compensación por una Lesión Relacionada con el Trabajo o Enfermedad Ocupacional
(Rev. 3/07)		 WORDSpanish
DWC042 Beneficiary Claim for Death Benefits
(Rev. 4/10)		 WORDEnglish
DWC042 Beneficiary Claim for Death Benefits
(Rev. 4/10)		 PDFEnglish
DWC042S Reclamación del Beneficiario para Obtener Beneficios por Causa de Muerte
(Rev. 4/10)		 WORDEnglish
DWC042S Reclamación del Beneficiario para Obtener Beneficios por Causa de Muerte
(Rev. 4/10)		 PDFSpanish
DWC044 Election to Engage in Arbitration
(Rev. 06/12, for disputes filed on or after June 1, 2012)		 PDFEnglish
DWC044 Election to Engage in Arbitration
(Rev. 10/05, for disputes filed on or before May 31, 2012)		 PDFEnglish
DWC044S Elección para Participar en un Arbitraje
(Rev. 06/12, para disputas que son presentadas en o después del 1º de junio de 2012)		 PDFSpanish
DWC045 Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC)
(Rev. 11/11, for use beginning 12/1/11)		 PDFEnglish
DWC045A Request for a Medical Contested Case or SOAH Hearing
(Rev. 09/07)		 PDFEnglish
DWC045AS Solicitud para una Audiencia para Disputar Beneficios Médicos o Audiencia en la Oficina Estatal de Audiencias Administrativas (SOAH, por sus Siglas en Inglés)
(Rev. 10/07)		 PDFSpanish
DWC045M Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision (BRC-MFD)
(Rev. 06/12, for disputes filed on or after June 1, 2012)		 PDFEnglish
DWC045MS Solicitud para Programar, Reprogramar, o Cancelar una Conferencia para Revisión de Beneficios para Apelar la Decisión de una Disputa por Honorarios Médicos (Benefit Review Conference to Appeal a Medical Fee Dispute Decision –BRC-MFD, por su nombre y siglas en inglés)
(Rev. 06/12, para disputas que son presentadas en o después del 1º de junio de 2012)		 PDFSpanish
DWC045S Solicitud para Programar, Reprogramar, o Cancelar una Conferencia para Revisión de Beneficios (Benefit Review Conference -BRC, por su nombre y siglas en inglés)
(Rev. 11/11, para usarse a partir de 12/1/11)		 PDFSpanish
DWC046 Employee's Request for Acceleration of Impairment Income Benefits
(Rev. 10/05)		 PDFEnglish
DWC046S Solicitud del Trabajador Lesionado para Recibir un Pago Acelerado de Beneficios por Causa del Impedimento Corporal
(Rev. 10/05) 		PDFSpanish
DWC047 Employee’s Request for Advance of Benefits
(Rev. 03/12)		 PDFEnglish
DWC047S Solicitud del Empleado para Obtener Beneficios por Adelantado
(Rev. 03/12)		 PDFSpanish
DWC048 Request for Travel Reimbursement / Solicitud de Reembolso
(Rev. 06/06)		 PDFEnglish / Spanish
DWC049 Request to Schedule a Medical Contested Case Hearing (MCCH)
(Rev. 06/12, for disputes filed on or after June 1, 2012)		 PDFEnglish
DWC049S Solicitud para Programar una Audiencia para Disputar Beneficios Médicos (Medical Contested Case Hearing –MCCH, por su nombre y siglas en ingles)
(Rev. 06/12, para disputas que son presentadas en o después del 1º de junio de 2012)		 PDFSpanish
DWC051 Employee's Election for Commuted (Lump Sum) Impairment Income Benefits
(Rev. 11/08)		 PDFEnglish
DWC052 Application for Supplemental Income Benefits
(Rev. 04/09)		 PDFEnglish
DWC052S Aplicación del trabajador para beneficios de ingresos suplementales
(Rev. 04/09)		 PDFSpanish
DWC053 Employee Request to Change Treating Doctor
(Rev. 03/12)		 PDFEnglish
DWC053S Solicitud del Empleado para Cambiar de Médico de Tratamiento
(Rev. 03/12)		 PDFSpanish
DWC054 Notice to Employee: Intention to Request Division Permission to Adjust Benefits
(Rev. 10/05)		 PDFEnglish
DWC054S Aviso al/a la Empleado/a: Intencion de Solicitar permiso a la División para Ajuste de Beneficios
(Rev. 10/05)		 PDFSpanish
DWC055 Request to Adjust Average Weekly Wage for Seasonal Employee
(Rev. 10/05)		 PDFEnglish
DWC055S Solicitud de Ajuste al Salario Medio Semanal de un(a) Empleado/a de Temporada
(Rev. 10/05)		 PDFSpanish
DWC056 Carrier's Request for Seasonal Employee Wage Information from Texas Workforce Commission Records
(Rev. 10/05)		 PDFEnglish
DWC057 Request for Extension of Maximum Medical Improvement for Spinal Surgery
(Rev. 10/05)		 PDFEnglish
DWC057s Solicitud para Extensión de Mejoramiento Máximo Médico por Cirugía de la Columna Vertebral
(Rev. 07/08)		 PDFSpanish
DWC058 Request for Interlocutory Order
(Rev. 09/07)		 PDFEnglish
DWC060 Medical Fee Dispute Resolution Request
(Rev. 06/12, for disputes filed on or after June 1, 2012)		 PDFEnglish
DWC060 Medical Fee Dispute Resolution Request/Response
(Rev. 02/07, for disputes filed on or before May 31, 2012)		 PDFEnglish
DWC060 Medical Fee Dispute Resolution Request/Response
(Rev. 02/07, for disputes filed on or before May 31, 2012)		 WORDEnglish
DWC060s Solicitud para Resolución de Disputas por Honorarios Médicos/Respuesta
(Rev. 2/07, for disputes filed on or before May 31, 2012)		 PDFSpanish
DWC060S Solicitud para Resolución de Disputas por Honorarios Médicos
(Rev. 06/12, para disputas que son presentadas en o después del 1º de junio de 2012)		 PDFSpanish
DWC060S Solicitud para Resolución de Disputas por Honorarios Médicos/Respuesta
(Rev. 2/07, for disputes filed on or before May 31, 2012)		 WORDSpanish
DWC062 Explanation of Benefits
(Rev. 07/07)		 PDFEnglish
DWC064 Medical Interlocutory Order Request - Continued Use of a Drug Previously Prescribed and Dispensed and Excluded from TDI-DWC’s Closed Formulary
(Rev. 8/11)		 PDFEnglish
DWC065 Application for Inclusion on Registry of Private Providers of Vocational Rehabilitation Services
(Rev. 1/11)		 WORDEnglish
DWC065 Application for Inclusion on Registry of Private Providers of Vocational Rehabilitation Services
(Rev. 1/11)		 PDFEnglish
DWC066 Statement of Pharmacy Services
(Rev. 12/11)		 PDFEnglish
DWC069 Report of Medical Evaluation
(Rev. 6/11) Sample Notice for Health Care Provider (PDF, Word)		 PDFEnglish
DWC070 Instructions For Completing The ADA J515 Dental Claim Form For Texas Workers' Compensation Claims
(Rev. 10/05)		 PDFEnglish
DWC073 Work Status Report
(Rev. 02/11)		 PDFEnglish
DWC074 Description of Injured Employee’s Employment
(Rev. 9/09)		 PDFEnglish
DWC081 Agreement Between General Contractor and Sub-Contractor to Provide Worker's Compensation Insurance
(Rev. 10/05)		 PDFEnglish
DWC081S Acuerdo Entre el Contratista General y el Sub Contratista
(Rev. 09/07)		 PDFSpanish
DWC082 Agreement for Motor Carriers and Owner Operators
(Rev. 10/05)		 PDFEnglish
DWC083 Agreement for Certain Building and Construction Workers
(Rev. 10/05)		 PDFEnglish
DWC083S Acuerdo para Ciertos Trabajadores de Edificación y Construcción
(Rev. 09/06)		 PDFSpanish
DWC084 Exception to Application of Joint Agreement for Certain Building and Construction Workers
(Rev. 10/05)		 PDFEnglish
DWC085 Agreement Between General Contractor and Subcontractor to Establish Independent Relationship
(Rev. 10/05)		 PDFEnglish
DWC085S Acuerdo Entre el Contratista General y el Sub Contratista Para Establecer una Relación Independiente
 PDFSpanish
DWC101 Program Review Report
(Rev. 08/06)		 WORDEnglish
DWC101 Program Review Report
(Rev. 08/06)		 PDFEnglish
DWC102 Accident Prevention Plan Cover Sheet
(Rev. 08/06)		 WORDEnglish
DWC102 Accident Prevention Plan Cover Sheet
(Rev. 08/06)		 PDFEnglish
DWC103 Approved Professional Source Safety Consultant Application
(Rev. 12/06) Note: The Approved Professional Source designation applies only to Loss Control Representatives of Texas Mutual Insurance Company as of September 1, 2005. 		WORDEnglish
DWC104 Employer Request for DWC Safety Consultation
(Rev. 08/06)		 WORDEnglish
DWC104 Employer Request for DWC Safety Consultation
(Rev. 08/06)		 PDFEnglish
DWC105 Accident Prevention Services Worksheet
(Rev. 04/09)		 PDFEnglish
DWC109 Accident Prevention Services Annual Report
(Rev. 12/05)		 PDFEnglish
DWC109 Accident Prevention Services Annual Report
(Rev. 12/05)		 WORDEnglish
DWC150 Notice of Representation or Withdrawal of Representation
(Rev. 10/05)		 PDFEnglish
DWC151 Attorney Application for Web Access
(Rev. 10/05)		 PDFEnglish
DWC152 Application for Attorney's Fees
(Rev. 10/05)		 PDFEnglish
DWC153 Request for Copies of Confidential Claimant Information
(Rev. 10/06) - Effective September 1, 2006, requests for a claim file, medical dispute resolution file, and/or an indemnity resolution file must be made on the newly revised DWC-153 form (10/2006). A requestor must be eligible by statute to receive the		 PDFEnglish
DWC153s Solicitud para Obtener Copias de la Información Confidencial del Reclamante
(Rev. 07/08)		 PDFSpanish
DWC155 Request for Record Check
(Rev. 10/05)		 PDFEnglish
DWC156 Prospective Employment Authorization and Certification
(Rev. 10/05)		 PDFEnglish
DWC156S Certificación Y Autorización De Un Posible Empleo
(Rev. 10/06)		 PDFSpanish
DWC205 Locations of Employer’s Business(es)
Addendum to DWC Form-005 or DWC Form-020 (Rev. 11/10)		 PDFEnglish
DWC205S Locaciones del Negocio(s) del Empleador
Suplemento para el Formulario DWC005 o Formulario DWC020 (Rev. 11/10)		 PDFSpanish
DWC210 Surety Bond for Certified Self-Insurance Liabilities
(Rev. 1/06)		 PDFEnglish
DWC210 Surety Bond for Certified Self-Insurance Liabilities
(Rev. 1/06)		 WORDEnglish
DWC215 Surety Bond Amount Rider
(Rev. 1/06)		 WORDEnglish
DWC215 Surety Bond Amount Rider
(Rev. 1/06)		 PDFEnglish
DWC216 Surety Bond Name Change Rider
(Rev. 1/06)		 PDFEnglish
DWC216 Surety Bond Name Change Rider
(Rev. 1/06)		 WORDEnglish
DWC223 Documentary Irrevocable Standby Letter of Credit
(Rev. 01/07)		 PDFEnglish
DWC223 Documentary Irrevocable Standby Letter of Credit
(Rev. 01/07)		 WORDEnglish
DWC224 Documentary Irrevocable Standby Letter of Credit ("Confirmation")
(Rev. 01/07)		 PDFEnglish
DWC224 Documentary Irrevocable Standby Letter of Credit ("Confirmation")
(Rev. 01/07)		 WORDEnglish
DWC225 Self-Insurer's Agreement to Post Documentary Irrevocable Standby Letter of Credit
(Rev. 01/07)		 WORDEnglish
DWC225 Self-Insurer's Agreement to Post Documentary Irrevocable Standby Letter of Credit
(Rev. 01/07)		 PDFEnglish
DWC226 Parental Guaranty
(Rev. 01/07)		 PDFEnglish
DWC226 Parental Guaranty
(Rev. 01/07)		 WORDEnglish
DWC227 Parental Guaranty for Less than Wholly Owned Subsidiary
(Rev. 01/07)		 WORDEnglish
DWC227 Parental Guaranty for Less than Wholly Owned Subsidiary
(Rev. 01/07)		 PDFEnglish
DWC228 Power of Attorney
(Rev. 01/07)		 PDFEnglish
DWC228 Power of Attorney
(Rev. 01/07)		 WORDEnglish
DWC-EDI-01 EDI TRADING PARTNER PROFILE
 WORDEnglish
EDI-02 Insurance Carrier or Trading Partner Medical Electronic Data Interchange (EDI) Profile
(Rev. 06/11)		 PDFEnglish
EDI-03 Medical EDI Compliance Coordinator and Trading Partner Notification
(Rev. 06/11)		 PDFEnglish
New Employee Notice English New Employee Notice
(covered and non-covered employers shall notify their employees of coverage status, in writing)		 PDFEnglish
New Employee Notice Spanish New Employee Notice
(covered and non-covered employers shall notify their employees of coverage status, in writing)		 PDFSpanish
Notice 5 Notice to Employees Concerning Workers' Compensation in Texas
(must be posted for employees to read)		 PDFEnglish
Notice 5 Spanish Notice to Employees Concerning Workers' Compensation in Texas
(must be posted for employees to read)		 PDFSpanish
Notice 6 Notice to Employees Concerning Workers' Compensation in Texas
(must be posted for employees to read)		 PDFEnglish
Notice 6 Spanish Notice to Employees Concerning Workers' Compensation in Texas
(must be posted for employees to read)		 PDFSpanish
Notice7e Notice to employees concerning Workers' Compensation in Texas
English (Rev. 8/00)		 WORDEnglish
Notice7e Notice to employees concerning Workers' Compensation in Texas
English (Rev. 8/00)		 PDFEnglish
Notice7r Notice to Certified Self-Insured Employer
Rules (Rev. 7/94)		 WORDEnglish
Notice7r Notice to Certified Self-Insured Employer
Rules (Rev. 7/94)		 PDFEnglish
Notice7s Notice to employees concerning Workers' Compensation in Texas
Spanish (Rev. 8/00)		 WORDSpanish
Notice7s Notice to employees concerning Workers' Compensation in Texas
Spanish (Rev. 8/00)		 PDFSpanish
Notice 8 English Required Workers' Compensation Coverage
(building or construction projects for governmental entities)		 PDFEnglish
Notice 8 Spanish Required Workers' Compensation Coverage
(building or construction projects for governmental entities)		 PDFSpanish
Notice 9 English Notice Regarding Certain Work-Related Communicable Diseases and Eligibility for Workers' Compensation Benefits
(law enforcement officers, fire fighters, emergency medical service employees, paramedics, and correctional officers)		 PDFEnglish
Notice 9 Spanish Notice Regarding Certain Work-Related Communicable Diseases and Eligibility for Workers' Compensation Benefits
(law enforcement officers, fire fighters, emergency medical service employees, paramedics, and correctional officers)		 PDFSpanish
PLN01 Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
(Rev. 10/05)		 WORDEnglish
PLN01 Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
(Rev. 10/05)		 PDFEnglish
PLN01S Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
(Rev. 01/10)		 WORDSpanish
PLN02 Notification of First Temporary Income Benefit Payment (124.2(e)(1))
(Rev. 10/05)		 WORDEnglish
PLN02 Notification of First Temporary Income Benefit Payment (124.2(e)(1))
(Rev. 10/05)		 PDFEnglish
PLN02S Notification of First Temporary Income Benefit Payment (124.2(e)(1))
(Rev. 01/10)		 WORDSpanish
PLN03 Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
(Rev. 10/05)		 WORDEnglish
PLN03 Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
(Rev. 10/05)		 PDFEnglish
PLN03S Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
(Rev. 01/10)		 WORDSpanish
PLN04 Notification of First Lifetime Income Benefit Payment (124.2(e)(1))
(Rev. 10/05)		 PDFEnglish
PLN04 Notification of First Lifetime Income Benefit Payment (124.2(e)(1))
(Rev. 10/05)		 WORDEnglish
PLN04S Notification of First Lifetime Income Benefit Payment (124.2(e)(1))
(Rev. 01/10)		 WORDSpanish
PLN05 Notification of First Death Benefit Payment (124.2(e)(1))
(Rev. 10/05)		 PDFEnglish
PLN05 Notification of First Death Benefit Payment (124.2(e)(1))
(Rev. 10/05)		 WORDEnglish
PLN05S Notification of First Death Benefit Payment (124.2(e)(1))
(Rev. 01/10)		 WORDSpanish
PLN06 Notification of Employer Full Salary Payment (124.2(e)(7))
(Rev. 10/05)		 PDFEnglish
PLN06 Notification of Employer Full Salary Payment (124.2(e)(7))
(Rev. 10/05)		 WORDEnglish
PLN06S Notification of Employer Full Salary Payment (124.2(e)(7))
(Rev. 01/10)		 WORDSpanish
PLN07 Notification of Change of Indemnity Benefit Type (124.2(e)(4))
(Rev. 10/05)		 WORDEnglish
PLN07 Notification of Change of Indemnity Benefit Type (124.2(e)(4))
(Rev. 10/05)		 PDFEnglish
PLN07S Notification of Change of Indemnity Benefit Type (124.2(e)(4))
(Rev. 01/10)		 WORDSpanish
PLN08 Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
(Rev. 10/05)		 PDFEnglish
PLN08 Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
(Rev. 10/05)		 WORDEnglish
PLN08S Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
(Rev. 01/10)		 WORDSpanish
PLN09 Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
(Rev. 10/05)		 WORDEnglish
PLN09 Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
(Rev. 10/05)		 PDFEnglish
PLN09S Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
(Rev. 01/10)		 WORDSpanish
PLN10 Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
(Rev. 10/05)		 WORDEnglish
PLN10 Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
(Rev. 10/05)		 PDFEnglish
PLN10S Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
(Rev. 01/10)		 WORDSpanish
PLN11 Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h))
(Rev. 10/05)		 PDFEnglish
PLN11 Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h))
(Rev. 10/05)		 WORDEnglish
PLN11S Notice of Disputed Issues(s) and Refusal to Pay Benefits (124.2(h))
(Rev. 01/10)		 WORDSpanish
Sample Notice Aviso de Pago Insuficiente de los Beneficios de Ingresos
(Rev. 12/11)		 PDFSpanish
Sample Notice Notice of Underpayment of Income Benefits
(Rev. 12/11)		 PDFEnglish
LC153 Monetary Forfeiture Notice
Attachment/instructions		 PDFEnglish
LC153 Monetary Forfeiture Notice
Attachment/instructions		 WORD
FastForm for electronic fingerprint appointment FastPass Form for electronic fingerprint appointment
Rev 3/2012		 PDFEnglish
FastForm for fingerprint card Fingerprint Card Scan Authorization Form to submit with fingerprint card
Rev 3/2012		 PDFEnglish
FIN506 Licensing - Individual Application for Insurance License
Used by individuals not required to qualify by examination. Previously, form number LI011. Rev 3/2012		 PDFEnglish
FIN507 Licensing Application for Insurance Agency License
Used by corporations, partnerships, depository institions and other business entity eligible for an insurance agency license under the provisions of the Texas Insurance Code. Rev 3/2012		 PDFEnglish
FIN510 Licensing Application for Reinsurance Intermediary License
For individuals and entities to apply for a Reinsurance Intermediary License under the provisions of TIC, Chapter 4152. Rev 3/2012		 PDFEnglish
FIN511 Licensing Reinsurance Intermediary Biographical Affidavit
To register individuals to be associated to a Reinsurance Intermediary License. Rev 3/2012		 PDFEnglish
FIN519 CE Automatic Fines Transmittal
Continuing Education Fines		 PDFEnglish
FIN530 Request for Letter(s) of Certification
Rev 3/2012		 PDFEnglish
LHL202 Licensing Corporate Insurance Agents Bond (AKA Insurance Agency Bond)
Method of showing proof of financial responsibility to obtain corporate license.		 PDFEnglish
LHL208 ISR Transfer/Cancel
Employment Form		 PDFEnglish
LHL212 Application for Provider Registration
Application to become an Agent/Adjuster continuing education provider. 		PDFEnglish
LHL213 Application for Course Certification
Application for certification of CE course.		 PDFEnglish
LHL216 CE Exemption or Extension
Application for licensee CE Exemption or Extension. 		PDFEnglish
LHL238 Biographical Form
Entity/Change of Control		 PDFEnglish
LHL240 Course Assignment Form
Allows an existing provider to assign the right to give its course to another existing provider. Both must have active provider registrations.		 PDFEnglish
LHL250 Annual Nonresident Public Insurance Adjuster Affidavit
Fill-in On Screen and Print		 PDFEnglish
LHL256 Licensing Public Insurance Adjuster Bond
Certifies that the persons listed on the form are bound to the Texas Department of Insurance in the sum of $10,000 as specified at 28 Texas Administrative Code §19.705.		 PDFEnglish
LHL386 Provider Audit Affidavit
Used only by continuing education providers		 PDFEnglish
LHL388 Branch Office Address Change Request
 PDFEnglish
LHL389 Licensee Name/Address Change Request Form
 PDFEnglish
LHL 430 Medicare Plan Marketing Report
 EXCEL
LHL615 Licensee Request
TEXAS Qualifying Continuing Education Credit		 PDFEnglish
LHL617 Request for Association Credit Accepted by TDI
 PDFEnglish
LHL627 Licensing Reinsurance Intermediary Agent For Service or Process Form
Nonresident Reinsurance Intermediary License applicant or licensee must use this form to appoint a Texas resident on whom a notice or order or process may be served.		 PDFEnglish
LHL628 Licensing Reinsurance Intermediary Bond
Method of showing proof of financial responsibility for a Reinsurance intermediary License.		 PDFEnglish
LHL629 Discount Health Care Program Operator Marketers Form
Use this form to provide a list of the marketers authorized to sell or distribute the program operator’s program under the program operator’s name, and a list of the marketing entities authorized to private label the program operator’s programs. An upd		 EXCEL
LHL630 Discount Health Care Program Operator Surety Bond Form
Use this form of an original surety bond in the principal amount of $50,000 to show Financial Responsibility. 		PDFEnglish
LHL631 Discount Health Care Program Operator Biographical Certificate Form
Form for Discount Health Care Program Operator Biographical Certificates. Follow the instructions within the form for completion.		 PDFEnglish
LHL632 Discount Health Care Program Operator Registration Form
Form for Registration as a Discount Health Care Program Operator.		 PDFEnglish
li004 Speciality Insurance License Application
 PDFEnglish
N/A CE Example Course Evaluation
Sample Only		 PDFEnglish
FIN111 Health Entities NAIC Checklist
Health Filing Requirements NAIC Checklist		 PDFEnglish
FIN116 HMO Supplement - Annual Information
HMO Supplement - Annual Information		 PDFEnglish
FIN117 TDI Instructions for Filing CPA Audited Financial Statements
TDI Instructions for Filing CPA Audited Financial Statements		 PDFEnglish
FIN119 Life, Accident and Health Insurers NAIC Checklist
Life, Accident and Health Insurers Filing Requirements NAIC Checklist		 PDFEnglish
FIN121 Analysis of Surplus Form for Life Accident and Health (TX Domestics only)
Analysis of Surplus Form for Life Accident and Health Companies (TX Domestics only)		 PDFEnglish
FIN122 Property & Casualty Insurers NAIC Checklist
Property & Casualty Insurers Filing Requirements NAIC Checklist		 PDFEnglish
FIN123 TDI Supplement Form for County Mutuals
Texas Supplement Form for County Mutuals		 PDFEnglish
FIN124 Analysis of Surplus Form - Property and Casualty Companies (TX Domestic only)
Analysis of Surplus Form - Property and Casualty Companies (TX Domestic only)		 PDFEnglish
FIN126 Fraternal Benefit Societies NAIC Checklist
Fraternal Benefit Societies Filing Requirements NAIC Checklist		 PDFEnglish
FIN127 Title Insurers NAIC Checklist
Title Insurers Filing Requirements NAIC Checklist		 PDFEnglish
FIN128 Annual Statement Blank - Farm Mutual Companies
Annual Statement Blank - Farm Mutual Companies		 PDFEnglish
FIN128 Annual Statement Blank - Farm Mutuals
Annual Statement Blank - Farm Mutuals		 EXCEL
FIN129 Prepaid Legal Services Corporation Annual Statement
Annual Statement Blank - Prepaid Legal Companies		 EXCEL
FIN129 Prepaid Legal Services Corporation Annual Statement Blank
Annual Statement Blank - Prepaid Legal Companies		 PDFEnglish
FIN131 Notice of Dividend or Distribution Pursuant to 28 TAC §7.203(n)
Solvency		 PDFEnglish
FIN138 Texas Supplemental "A" for County Mutuals Form
Texas Supplemental "A" for County Mutuals Form		 PDFEnglish
FIN 150 Texas Negotiated Deductible Workers' Compensation Form
 PDFEnglish
FIN202 Policyholder Dividend Disbursement Application - Casualty Dividends
 WORDEnglish
FIN202 Texas Casualty Dividend Disbursement Application Form
Texas Casualty Dividend Disbursement Application Form		 PDFEnglish
FIN203 Policyholder Dividend Disbursement Application
 WORDEnglish
FIN203 Texas Property Dividend Disbursement Application Form
Texas Property Dividend Disbursement Application Form		 PDFEnglish
FIN230 Release of Contributions
Release of Contributions		 PDFEnglish
FIN231 Reserve Summary
fin231ressum		 PDFEnglish
FIN232 Reserve Valuation Sheets
fin232resvalins		 PDFEnglish
FIN242 Analysis of Surplus - Fraternal Societies (Commercially Domiciled and TX Domestics) - Requried of Foreign companies filing Policyholder Dividend Applications
Analysis of Surplus Form - Fraternal Benefit Societies (Commercially Domiciled and TX Domestics) - Required of Foreign companies filing Policyholder Dividend Applications		 PDFEnglish
FIN243 Analysis of Surplus - Title Annual Statement (File this form if TX domestic comnpany, commercially domiciled Title company, or foreign title company filing a policyholder dividend in TX
Analysis of Surplus - Title Companies (File this form if TX domestic company, commercially domiciled Title company, or foreign title company filing a policyholder dividend in TX 		PDFEnglish
FIN244 CPA Audited Financial Statements - Intent Form
Register a CPA to file an audited financial statement		 PDFEnglish
FIN246 Affidavit for Exemption form filing
Authorization to file an exemption		 PDFEnglish
FIN248 Net Premium Summary
fin248sumofinv		 PDFEnglish
FIN249 Inventory of Insurance in Force by Age of Issue or Reseving Year
fin249invofins		 PDFEnglish
FIN251 Annual Statement Blank - Mutual Assessments, Burials, LMAs
Annual Statement Blank - Mutual Assessments, Burials, LMAs		 PDFEnglish
FIN251 Annual Statement Blank - Mutual Assessments, LMA's, Burials
Annual Statement Blank - Mutual Assessments, LMA's, Burials		 EXCEL
FIN252 HMO Quarterly Supplement
HMO Quarterly Supplement		 PDFEnglish
FIN483 Transactions Cash Receipts Transmittal Form
 PDFEnglish
FIN483 Transactions Cash Receipts Transmittal Form
 WORDEnglish
FIN300 Company Name Application
Application to reserve a company name		 PDFEnglish
FIN301 Life/Health Application for Certificate of Authority
Compliance with statutes		 PDFEnglish
FIN302 HMO Application for Certificate of Authority
Compliance with statutes		 PDFEnglish
FIN303 P&C Application for Certificate of Authority
Compliance with statutes		 PDFEnglish
FIN304 Standard Coverages Page
Declares property and casualty lines of business to be listed on Certificate of Authority		 PDFEnglish
FIN305 Assumed Name Certificate
Indicates what the assumed name will be		 PDFEnglish
FIN306 Officers and Directors Page
Complete Listing of all Current Officers and Directors - compliance with statutes		 PDFEnglish
FIN307 Attorney-in-Fact and Underwriters Page
Lists the Attorney-in-Fact and Underwriters of Lloyds and Reciprocals		 PDFEnglish
FIN308 Budget Projection Form for Life Company
Assists in financial review for admission/licensure of a Life Company		 PDFEnglish
FIN309 Budget Projection Form for P&C Company
Assists in financial review for admission/licensure of a P&C Company		 PDFEnglish
FIN311 Biographical Affidavit
Compliance with statutes		 PDFEnglish
FIN313 Company License Customer Survey
Feedback from Applicants		 PDFEnglish
FIN316 Mortgage Guaranty Affidavit
Affidavit that verifies monoline authority		 PDFEnglish
FIN317 Reinsurer Affidavit
Verify applicants understanding of TDI rules		 PDFEnglish
FIN318 Trust Agreement (U.S. Branch)
Agreement between US branch and Texas bank establishing trust		 PDFEnglish
FIN320 Capital Changes Worksheet
Worksheet		 PDFEnglish
FIN321 Consent Order Waiver
Signature page for Commissioner's Order		 PDFEnglish
FIN325 State of Texas Statement of Retaliatory Fees and Requirements
Requirements for insurers, including Capital and Surplus Requirements; Fees; Deposit and Bonds; Premium Tax Requirements; and Additional Taxes		 PDFEnglish
FIN326 Businesss Plan Outline for Life, Accident & Health Company
Filing instruction		 PDFEnglish
FIN327 Business Plan Outline for P&C Company
Filing instruction		 PDFEnglish
FIN328 Abbreviated Business Plan
Filing instruction		 PDFEnglish
FIN329 Group Hospital Service Corporation
Guideline/Checklist		 PDFEnglish
FIN330 Mexican Casualty Admission Checklist
Filing instruction		 PDFEnglish
FIN331 Domestication of US Branch
Filing instruction		 PDFEnglish
FIN332 Domestic Life & Health Charter Amendment Checklist
Checklists for a Texas Life & Health Company Needing to Amend their Articles of Incorporation for Transactions such as Capital Increase/Decrease, Name Change, Home Office Change, and Adding or Deleting a Line of Business		 PDFEnglish
FIN333 Domestic P&C Charter Amendment Checklists
Checklists for a Texas P&C Company Needing to Amend their Articles of Incorporation for Transactions such as Capital Increase/Decrease, Name Change, Home Office Change, and Adding or Deleting a Line of Business		 PDFEnglish
FIN334 County Mutual Charter Amendment Checklist
Filing instruction		 PDFEnglish
FIN335 Farm Mutual Charter Amendment Checklist
Filing instruction		 PDFEnglish
FIN336 Local Mutual Aid or Burial Association Charter Amendment Guidelines
Filing instruction		 PDFEnglish
FIN337 Increase Authorized or Stated Capital
Filing instruction		 PDFEnglish
FIN338 Adding Variable Annuity Authority Checklist
Filing instruction		 PDFEnglish
FIN339 Adding Variable Life Authority Checklist
Filing instruction		 PDFEnglish
FIN340 Application to Amend Certificate of Authority
Filing instruction		 PDFEnglish
FIN341 Merger involving at least one Domestic Insurer
Filing instruction		 PDFEnglish
FIN342 Conversion of a Domestic Mutual Insurance Company
Filing instruction		 PDFEnglish
FIN343 Foreign Demutualization or Conversion Checklist
Filing instruction		 PDFEnglish
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		 PDFEnglish
FIN346 Checklist for Total and Partial Reinsurance Agreements involving two Foreign Companies
Filing instruction		 PDFEnglish
FIN347 Reinsurance of Mutual Assessment Company into a Stipulated Premium Company
Filing instruction		 PDFEnglish
FIN348 Assumption Certificate Guidelines for Life, Accident, and/or Health Business
Filing instruction		 PDFEnglish
FIN349 Withdrawal checklist
Filing instruction for an insurer wanting to withdraw or cease writing a line or lines of insurance		 PDFEnglish
FIN350 Re-enter Texas Market Subsequent to Withdrawal Guidelines
Filing instruction		 PDFEnglish
FIN351 Voluntary Dissolution Checklist
Instructions for a Texas-Domestic Company wanting to Dissolve and Cancel its Certificate of Authority		 PDFEnglish
FIN352 CCRC Biographical Affidavit Requirements
Biographical Affidavit requirements for Continuing Care Retirement Communities (CCRCs)		 PDFEnglish
FIN353 Texas-Domestic Insurers Biographical Affidavit and Fingerprint Requirements
Biographical Affidavit and Fingerprint requirements for Texas-Domestic Insurers		 PDFEnglish
FIN354 Foreign Insurers Biographical Affidavit and Fingerprint Requirements
Biographical Affidavit and Fingerprint requirements for foreign insurers		 PDFEnglish
FIN355 HMO Biographical Affidavit and Fingerprint Requirements
Biographical Affidavit and Fingerprint requirements for Health Maintenance Organizations (HMOs)		 PDFEnglish
FIN356 Texas Lloyds Insurers and Reciprocals Biographical Affidavit and Fingerprint Requirements
Biographical Affidavit and Fingerprint Requirements for Texas Lloyds Insurers and Reciprocals		 PDFEnglish
FIN357 HMO Certificate of Authority Application
Filing instruction		 PDFEnglish
FIN358 HMO D/B/A Filing Checklist
Filing Instruction		 PDFEnglish
FIN359 HMO Home Office Change Checklist
Filing Instruction		 PDFEnglish
FIN360 HMO- Name Change Checklist
Filing Instruction		 PDFEnglish
FIN361 HMO Service Area Expansion
Filing Instruction		 PDFEnglish
FIN363 HMO Merger Checklist
Merger Checklist		 PDFEnglish
FIN364 HMO Dissolution
Dissolution instructions		 PDFEnglish
FIN365 HMO Withdrawal Guidelines
Withdrawal guidelines		 PDFEnglish
FIN367 Form A-212 (Reciprocal)
Reciprocal companies complete for new or amended Certificate of Authority		 PDFEnglish
FIN368 Lloyds Incorporation Checklist
Filing instruction		 PDFEnglish
FIN369 Form A-211 (Lloyds)
Lloyds companies complete for new or amended Certificate of Authority		 PDFEnglish
FIN370 Charter Amendment Checklist for a Lloyds Plan
Instruction for Lloyds amendments, including Underwriter Substitution, Attorney-in-Fact Change, Name Change or Home Office Change, or Increase in Guaranty Fund or Surplus Contribution		 PDFEnglish
FIN371 Attorney-in-Fact Change for Foreign Lloyds or Reciprocals
Change checklist		 PDFEnglish
FIN372 Conversion of Lloyds to Stock P&C Insurer
Filing instruction		 PDFEnglish
FIN373 MEWA Application for Initial and Permanent Certificate of Authority
Filing instructions		 PDFEnglish
FIN374 MEWA Application to Do Business
Checklist		 PDFEnglish
FIN375 MEWA Application Form for Initial Certificate of Authority
Application Form		 PDFEnglish
FIN376 MEWA Officers, Directors, and Trustees Page
Form		 PDFEnglish
FIN377 MEWA Service of Process
Acknowledgment Form		 PDFEnglish
FIN378 MEWA Annual Filing Checklist
Filing instruction		 PDFEnglish
FIN381 CCRC Filing Requirements for Certificate of Authority
Filing instruction		 PDFEnglish
FIN382 CCRC 1 - Application for Certificate of Authority to do Business in Texas
CCRC Application for Certificate of Authority to do business in Texas		 PDFEnglish
FIN383 CCRC 2 - Application for Approval by the Commissioner for Release of Loan Reserve Fund Escrow Account Amounts In Excess of that Allowed by Rule
Application for Commissioners Approval to Release Loan Reserve Fund Escrow Amounts in Excess of that Allowed by rule		 PDFEnglish
FIN384 CCRC 3 - Officers and Directors Page
CCRC Officers and Directors Page		 PDFEnglish
FIN385 CCRC 4 - Biographical Data Form for a For-Profit CCRC
Biographical Data Form for a For-Profit CCRC		 PDFEnglish
FIN386 CCRC 4A - CCRC Biographical Affidavit for a Not-For-Profit CCRC
CCRC Biographical Affidavit for a Not-For-Profit CCRC		 PDFEnglish
FIN387 CCRC 5 - Acknowledgement of Delivery of Disclosure Statement
CCRC Acknowledgement of Delivery of Disclosure Statement		 PDFEnglish
FIN388 CCRC 6 - Format for Disclosure Statement
Detailed instruction/format for submitting Disclosure Statement		 PDFEnglish
FIN389 CCRC Form #6A - CCRC Instructions for Preparation of Disclosure Statement
Outline of Instructions for Preparation of CCRC Disclosure Statement		 PDFEnglish
FIN390 CCRC 7 - Change of Control Statement
Guidelines and Statement		 PDFEnglish
FIN391 CCRC 8 - Certification of Changes to Disclosure Statement
Certification form		 PDFEnglish
FIN392 CCRC 9 - Notice of Request to Release Entrance Fee Escrow Funds
Attestation form		 PDFEnglish
FIN393 CCRC 10 - Notice of Request to Release Funds from the Reserve Fund Escrow Account
Attestation form		 PDFEnglish
FIN394 CCRC 11 - Notice by Provider of Re-Payment of Previously Released Funds to the Reserve Fund Escrow Account
Filing form		 PDFEnglish
FIN395 CCRC 12 - Affidavit of Re-payment of Previously Released Funds to the Reserve Fund Escrow Account
Filing form		 PDFEnglish
FIN396 CCRC 13 - Notice of Lien
Filing form		 PDFEnglish
FIN397 CCRC 14 - Calculations Concerning Conditions
Filing form		 PDFEnglish
FIN398 CCRC Name Change Checklist
CCRC Charter Amendment Checklist - Name Change		 PDFEnglish
FIN399 Joint Underwriting Association (JUA) Licensing (Initial or Renewal)
Filing instruction		 PDFEnglish
FIN400 Joint Underwriting Association (JUA) Application for Certificate of Authority
Filing form		 PDFEnglish
FIN401 Joint Underwriting Association (JUA) Supplemental Information (JUA-2A)
Filing checklist JUA-2A		 PDFEnglish
FIN402 Joint Underwriting Association (JUA) Application for Amended Certificate of Authority (JUA-2B)
Filing form JUA-2B		 PDFEnglish
FIN403 Continuing Care Retirement Community (CCRC) Release of Funds from Escrow
Filing instructions		 PDFEnglish
FIN404 Workers Compensation Group Self-Insurance Coverage Acknowledgement of Indemnity Agreement
Format Instructions		 PDFEnglish
FIN413 Texas Purchasing Group Registration Requirements
Memo to Purchasing Groups Outlining Filing Requirements		 PDFEnglish
FIN414 Notification to the Commissioner for Registration as a Purchasing Group - Form PG1
Form PG1 - used for the initial registration of a group that intends to do business in Texas		 PDFEnglish
FIN415 Annual Agent Report for Risk Retention and Purchasing Groups - Form PG3
Form PG3 required to be filed by any agent for a purchasing group and shown on Form PG1 or Form PG1R		 PDFEnglish
FIN416 Appointment of Commissioner as Agent - Form RRG/PG C1
Form RRG/PG PC1 required for all purchasing groups. Notarized form appoints Commissioner of Insurance as agent for the purchasing group.		 PDFEnglish
FIN417 Renewal/Amendment of Purchasing Group Registration - Form PG1R
Form PG1R - Form (notarized) and instructions used to report changes to the original registration and for annual renewal of Purchasing Groups, due by July 1.		 PDFEnglish
FIN418 Texas Risk Retention Group Registration Requirements
Memorandum outlining the requirements and forms required for registering a Risk Retention Group in Texas		 PDFEnglish
FIN419 Registration of a Foreign/Alien Risk Retention Group - Form RRG-A-122
Form RRG-A-122 required for initial registration and renewal of a Risk Retention Group that intends to do business in Texas.		 PDFEnglish
FIN420 Risk Retention Group Registration Requirements Checklist
Checklist provided to Risk Retention Groups to ensure all required documents are completed and submitted within required deadlines.		 PDFEnglish
FIN421 Evidence Filing Requirements for 2012 Surplus Lines Eligibility
Memorandum highlighting the filing requirements and due dates for evidence to obtain or maintain Surplus Lines eligibility in Texas		 PDFEnglish
FIN422 Foreign (U.S. domiciled) Surplus Lines Insurers Filing Requirements/Checklist
Instructions/Checklist for foreign (U.S. domiciled) Surplus Lines insurers that wish to obtain/maintain SL eligibility. See FIN421 for Memorandum to be utilized in conjunction with FIN422.		 PDFEnglish
FIN423 Alien (non-U.S. domiciled) Surplus Lines Insurers Filing Requirements/Checklist
Instructions/Checklist for alien (non-U.S. domiciled) Surplus Lines insurers that wish to obtain/maintain SL eligibility. See Form FIN421 for Memorandum to be utilized in conjunction with this Form FIN423.		 PDFEnglish
FIN424 Surplus Lines Company Business Outline
These are guidelines for Surplus Lines insurers when preparing the required 3 year business plan for Texas		 PDFEnglish
FIN425 Accredited/Trusteed Reinsurers Registration Requirements for 2012
Memorandum outlining 2012 filing requirements for reinsurers wanting to maintain their certification as Accredited or Trusteed Reinsurer.		 PDFEnglish
FIN426 Accredited/Trusteed Reinsurer Checklist, Form R-4
Form R-4 Checklist for Accredited/Trusteed Reinsurers listing filing requirements for reinsurers wanting to maintain their certification as Accredited or Trusteed Reinsurer. See FIN425 for memo with further instructions.		 PDFEnglish
FIN427 Submission for Reinsurance Accreditation, Form R-1
Form R-1 (notarized) submitted for Reinsurance Accreditation. See FIN425 for memo with further instructions.		 PDFEnglish
FIN428 Certificate of Assuming Insurer, Form R-3
Form R-3 (notarized form) Designates Commissioner of Insurance as Attorney for Service; submits to the COI to examine its books and records; submits to the jurisdiction of any court of competent jurisdiction in Texas for adjudication of any issues.		 PDFEnglish
FIN429 Accredited/Trusteed Reinsurer Business Plan Outline
Guide to key elements that might be included in a 3-year business plan for Accredited/Trusteed Reinsurers.		 PDFEnglish
FIN435 Initial Statutory Deposit Checklist
Checklist		 PDFEnglish
FIN436 Name Change for Securities on Deposit Checklist
Checklist		 PDFEnglish
FIN437 Substituting Securities on Deposit Checklist
Checklist		 PDFEnglish
FIN438 Withdrawal of Statutory Deposit Checklist
Withdrawal Checklist		 PDFEnglish
FIN439 Texas Comptroller's Wiring Instructions
Instructions		 PDFEnglish
FIN440 Instructions for Completing Securities Deposited Form 120
Instructions		 PDFEnglish
FIN441 Deposit Form 120 (FIN 441)
Form for companies		 PDFEnglish
FIN442 Deposit Form 120 (FIN442)
Form for insurance agencies		 PDFEnglish
FIN443 Deposit Form 120 (FIN443)
Form for LLoyds companies		 PDFEnglish
FIN444 Instructions for Completing Form 121
Instructions 		PDFEnglish
FIN445 Securities Withdrawal Form 121 (FIN445)
Form for companies		 PDFEnglish
FIN446 Withdrawal Form 121 (Agency)
Withdrawal		 PDFEnglish
FIN447 Securities Withdrawal Form 121 (FIN447)
Form for LLoyds		 PDFEnglish
FIN448 Instructions for Lloyds Placing Securities in Joint Control
Instructions		 PDFEnglish
FIN449 Instructions for Companies Placing Securities in Joint Control
Instructions		 PDFEnglish
FIN450 Joint Control Agreement
Agreement		 PDFEnglish
FIN451 Instructions for HMOs Placing Securities on Deposit
Instructions		 PDFEnglish
FIN452 HMO Pledge Letter Example
Sample Letter		 PDFEnglish
FIN453 Declaration of Trust 1.10 (Policyholders Only)
Declaration		 PDFEnglish
FIN454 Declaration of Trust 1.10 (Policyholders or Creditors)
Declaration		 PDFEnglish
FIN455 Declaration of Trust 1.10 (State Specific Policyholders Only)
Declaration		 PDFEnglish
FIN456 Declaration of Trust 1.10 (State Specific Policyholders or Creditors)
Declaration		 PDFEnglish
FIN457 Declaration of Trust 8.24 (Mexican Casualty Companies)
Declaration		 PDFEnglish
FIN458 Declaration of Trust 9.12 (Title Companies)
Declaration - (Electronic Form Not Yet Available)		 PDFEnglish
FIN459 Declaration of Trust 21.46 (Retaliatory)
Declaration - (Electronic Form Not Yet Available)		 PDFEnglish
FIN460 Declaration of Trust 861.252a (Domestic P&C Companies), formerly 8.05-1
Declaration		 PDFEnglish
FIN461 Declaration of Trust 861.252b (Foreign P&C Companies)
Declaration		 PDFEnglish
FIN462 Workers' Comp Self-Insured Group Pledge/Trust Document
 PDFEnglish
FIN463 CD Free of Liens Form
 PDFEnglish
FIN464 Bond of Administrator or Service Company For A Workers' Compensation Self-Insured Group
Format Instructions		 PDFEnglish
FIN465 Workers Compensation Self-Insurance Group Application
Application for Certificate of Approval to Conduct Workers Compensation Self-Insurance Group (SIG) Business		 PDFEnglish
FIN466 Workers Compensation Self-Insurance Group (SIG) Application Checklist
Application Checklist for Workers Compensation Self-Insurance Groups (SIG) 		PDFEnglish
FIN467 Workers Compensation Self-Insurance Group (SIG) Employer Membership Form
Employer Membership Form for Workers Compensation Self-Insurance Groups		 PDFEnglish
FIN468 Workers Compensation Self-Insurance Group (SIG) Notification Form
Mandatory Notification to the Commissioner of Insurance Regarding Any One of a Variety of Possible Changes that a Workers Compensation Self-Insurance Group Makes		 PDFEnglish
FIN469 Workers Compensation Self-Insurance Group (SIG) Termination of Certificate of Approval Checklist
Checklist for a Workers Compensation Self-Insurance Group (SIG) to Apply for Termination of its Certificate of Approval		 PDFEnglish
FIN470 Workers Compensation Self-Insurance Group (SIG) Merger Checklist
Checklist for a Workers Compensation Self-Insurance Group (SIG) to Merge with Another SIG Engaged in the Same or Similar Type of Business		 PDFEnglish
FIN471 Workers Compensation Self-Insurance Group (SIG) 5% Investments
Instruction for a Workers Compensation Self-Insurance Group (SIG) Regarding Authorized Investments for Meeting Minimum Capital and Surplus and Reserves		 PDFEnglish
FIN472 Workers Compensation Self-Insurance Group (SIG) Hazardous Financial Condition Notice
Instruction and Checklist for a Workers Compensation Self-Insurance Group (SIG) should it become Insolvent or Discover a Hazardous Financial Condition		 PDFEnglish
FIN473 Workers Compensation Self-Insurance Group (SIG) Changes to Administrator/Service Company Agreements Checklist
Checklist for a Workers Compensation Self-Insurance Group (SIG) if there are any Changes to Agreements or New Agreements are Entered Into with An Administrator/Service Company		 PDFEnglish
FIN474 Workers Compensation Self-Insurance Group (SIG) Change in Security for Incurred Liabilities Form
Security Deposit Instructions for a Workers Compensation Self-Insurance Group (SIG)		 PDFEnglish
FIN475 Workers Compensation Self-Insurance Group (SIG) Change in Performance or Fidelity Bond Checklist
Checklist for a Workers Compensation Self-Insurance Group (SIG) for a Change in Performance or Fidelity Bond		 PDFEnglish
FIN476 Workers Compensation Self-Insurance Group (SIG) Changes to Corporate Governance Documents Checklist
Checklist for a Workers Compensation Self-Insurance Group (SIG) to Make a Change to its Corporate Governance Documents, Including By-Laws, Articles of Association, Incorporation, or other Documentation used to Verify the Existence of the SIG and/or Trust		 PDFEnglish
FIN477 Workers Compensation Self-Insurance Group (SIG) Excess Insurance Checklist
Checklist for a Workers Compensation Self-Insurance Group (SIG) to Establish Excess Insurance for Losses		 PDFEnglish
FIN478 Workers Compensation Self-Insurance Group (SIG) Financial Pro Forma
Financial Pro Forma for a Workers Compensation Self-Insurance Group (SIG)		 PDFEnglish
FIN479 Workers Compensation Self-Insurance Group (SIG) Movement of Books and Records Checklist
Checklist for a Workers Compensation Self-Insurance Group (SIG) to Request to Move its Books and Records out of Texas		 PDFEnglish
FIN480 Workers Compensation Self-Insurance Group (SIG) Increase or Decrease in Membership Checklist
Checklist for a Workers Compensation Self-Insurance Group (SIG) if there is an Increase or Decrease in Membership		 PDFEnglish
FIN139 D. Premium Finance AOR - Annual Operations Report (FIN139 pages 2-7)
A PFC is required to complete & return an AOR along w/an Assessment Fee, by Apr. 1 following each annual reporting yr. A completed AOR provides premium finance statistical info & answers pertaining to the company’s operations.		 PDFEnglish
fin163pf1crenewal 2011 Premium Finance Renewal Form
Premium Finance Renewal Form PF1C		 PDFEnglish
FIN486 Annual Report for Administrators
 PDFEnglish
FIN487 Annual Report for Insurers/HMOs
 PDFEnglish
FIN488 Annual Report Exhibits A-E
 EXCEL
FIN489 Application for Certificate of Authority as an Administrator
 PDFEnglish
FIN490 Certification of Financial Statement
 PDFEnglish
LHL081 Administrator Biographical
 PDFEnglish
LHL082 Service of Process for Administrators
 PDFEnglish
LHL177 Licensing Checklist for TPA Name Change
Checklist		 PDFEnglish
LHL177 TPA Name Change
Checklist		 WORDEnglish
TPAFRMARINSTR Instructions for FIN486 and FIN487
Instructions for filing the TPA Annual Report 		PDFEnglish
FR028 Suspected Insurance Fraud Report (SIU) Form
 WORDEnglish
FR028 Suspected Insurance Fraud Report (SIU) Form
 PDFEnglish
FR029 Suspected Insurance Fraud Reporting Form for Consumer
Consumer Fraud Report		 WORDEnglish
FR029 Suspected Insurance Fraud Reporting form for Consumers
 PDFEnglish
PC396 Insurer Registration Form For Access to Helpinsure.com
 PDFEnglish
LHL020 Transmittal Checklist for Life/Health Form Filings
Required document for the submission of forms for review/approval to the Filing Intake Division.		 PDFEnglish
LHL243 Transmittal Form for Certain Miscellaneous Life/Health Documents
Required document for the submission of reports filed for information to the Filings Intake Division. 		PDFEnglish
LHL640 Quarterly Consumer Information Data Call
Quarterly reporting form for Accident & Health and HMO experience in Texas		 PDFEnglish
LHL657 Mandated Benefits Data Call
Annual reporting form for Mandated Benefits Data Call		 PDFEnglish
LHL005 URA Application Form
Application to apply for a URA Certification		 PDFEnglish
LHL006 Independent Review Organization Application
Application to apply for a IRO Certification		 PDFEnglish
LHL007 Name Change for Health Care Utilization Review Agent
 PDFEnglish
LHL009 Request for Review by an IRO
[ En Español ] - Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity		 PDFSpanish
LHL009 Request for Review by an IRO
Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity		 PDFEnglish
LHL011 Individual HMO Checklist
Used as guide to indicate the mandatory provisions and benefits required in an Evidence of Coverage		 PDFEnglish
LHL012 Physician/Provider Contract Checklist
Used as guide to indicate the mandatory provisions and benefits required in a Provider Contract		 PDFEnglish
LHL234 Application Package
 PDFEnglish
LHL234 Application Package - Web Enterable
 WORDEnglish
LHL234 Application Package - Web Enterable
 RTFEnglish
LHL234a Other Professional Degrees
A		 PDFEnglish
LHL234a Other Professional Degrees - Web Enterable
A		 WORDEnglish
LHL234a Other Professional Degrees - Web Enterable
A		 RTFEnglish
LHL234b Other Post-Graduate Education
B		 PDFEnglish
LHL234b Other Post-Graduate Education - Web Enterable
B		 RTFEnglish
LHL234b Other Post-Graduate Education - Web Enterable
B		 WORDEnglish
LHL234c Other Work History
C		 PDFEnglish
LHL234c Other Work History - Web Enterable
C		 RTFEnglish
LHL234c Other Work History - Web Enterable
C		 WORDEnglish
LHL234d Other Current Hospital Affiliations
D		 PDFEnglish
LHL234d Other Current Hospital Affiliations - Web Enterable
D		 WORDEnglish
LHL234d Other Current Hospital Affiliations - Web Enterable
D		 RTFEnglish
LHL234e Other Previous Hospital Affiliations
E		 PDFEnglish
LHL234e Other Previous Hospital Affiliations - Web Enterable
E		 RTFEnglish
LHL234e Other Previous Hospital Affiliations - Web Enterable
E		 WORDEnglish
LHL234f Other Practice Locations
F		 PDFEnglish
LHL234f Other Practice Locations - Web Enterable
F		 RTFEnglish
LHL234f Other Practice Locations - Web Enterable
F		 WORDEnglish
LHL234g Malpractice Claims History
G		 PDFEnglish
LHL234g Malpractice Claims History - Web Enterable
G		 RTFEnglish
LHL234g Malpractice Claims History - Web Enterable
G		 WORDEnglish
LHL252 Form CCP/Figure 1 Required Disclosure Notice for All Individual HMO Consumer Choice Benefit Plans Issued in Texas
Disclosure Notice to Purchase a Consumer Choice Health Benefit Plan for Individual HMO 		PDFEnglish
LHL254 Form CCP/Figure 1 Required Disclosure Notice for All Group HMO Consumer Choice Benefit Plans Issued in Texas
Disclosure Notice to Purchase a Consumer Choice Health Benefit Plan for Group HMO		 PDFEnglish
LHL259 Transmittal Checklist for HMO Filings
Used by companies to submit forms for policy review/approval.		 PDFEnglish
LHL358 Small Employer Consumer Choice Evidence of Coverage Checklist
Checklist		 PDFEnglish
LHL359 Individual Consumer Choice Evidence of Coverage Checklist
Checklist		 PDFEnglish
LHL360 Large Employer Consumer Choice Evidence of Coverage Checklist
Checklist		 PDFEnglish
LHL361 Workers Compensation Utilization Review Adverse Determination Summary
Checklist 		EXCEL
LHL380 Evidence of Coverage Requirements (Small Employer & Conversion Plans)
Checklist		 PDFEnglish
LHL381 Evidence of Coverage Requirements (Large Employer & Conversion Plans)
Checklist		 PDFEnglish
LHL385 Delegated Entities & Delegated Third Parties
Checklist		 PDFEnglish
LHL390 WC Network Biographical Affidavit Form
Workers' Compensation Health Care Network Biographical Affidavit		 PDFEnglish
LHL390 WC Network Biographical Affidavit Form
Workers' Compensation Health Care Network Biographical Affidavit		 WORD
LHL392 WC Network Application Certification Requirements Checklist
Workers' Compensation Health Care Network Application Certification Requirements Checklist		 PDFEnglish
LHL396 Credentialing Requirements Checklist
Individual Health Care Providers		 WORD
LHL396 Credentialing Requirements Checklist
Individual Health Care Providers		 PDFEnglish
LHL397 Credentialing Requirements Checklist
Health Care Facilities		 PDFEnglish
LHL397 Credentialing Requirements Checklist
Health Care Facilities		 WORD
LHL398 Health Maintenance Organization (HMO)
HMO Access Plan Checklist		 WORD
LHL398 Health Maintenance Organization (HMO)
Network Access Plan Checklist		 PDFEnglish
LHL399 WC Network Access Plan Checklist
List of requirements for a WC Network Access Plan		 WORD
LHL 416 WC Network - Network Adequacy Checklist
 PDFEnglish
LHL 417 WCNetwork Complaints Policies & Procedures
 PDFEnglish
LHL 418 WC Network Operations Checklist
 PDFEnglish
LHL 419 WC Network Credentialing Policy & Procedure Checklist
 PDFEnglish
LHL 420 WC Network Quality Improvement Checklist
 PDFEnglish
LHL423 Insurance Carrier Contract Checklist
Insurance Carrier Contract Checklist		 PDFEnglish
LHL424 Provider Contract Checklist
Provider Contract Checklist		 PDFEnglish
LHL425 WC Network Application Form
Workers' Compensation Health Care Network Application		 PDFEnglish
LHL425 WC Network Application Form
Workers' Compensation Health Care Network Application		 WORD
LHL426 WCNet configuration modification checklist
Workers' Compensation Network configuration modification checklist		 PDFEnglish
LHL427 Management Services Checklist
Management Services Checklist		 PDFEnglish
LHL432 HMO Claims Tool Policies & Procedures Checklist
 PDFEnglish
LHL433 HMO Complaints Policies & Procedures Checklist
 PDFEnglish
LHL434 HMO Credentialing Policies & Procedures Checklist
 PDFEnglish
LHL435 HMO Delegated Entities File Review Checklist
 PDFEnglish
LHL436 HMO Plan Operations Checklist
 PDFEnglish
LHL437 HMO Network Adequacy Checklist
 PDFEnglish
LHL438 HMO Provider Manual Checklist
 PDFEnglish
LHL439 HMO Quality Improvement Program Checklist
 PDFEnglish
LHL440 HMO Single Service Quality Improvement Program Checklist
 PDFEnglish
LHL441 HMO Single Service Accessibility & Availability Checklist
 PDFEnglish
LHL442 HMO Complaint File Review Checklist
Checklist used to review HMO complaint files.		 EXCEL
LHL443 HMO Credentialing File Review Checklist
Used to review HMO credentialing files		 EXCEL
LHL443 HMO Credentialinig File Review Checklist
HMO Credentialing File Review Checklist		 EXCEL
LHL445 Evidence of Coverage Requirements (Single Health Care Service Plan - Dental Care)
Checklist		 PDFEnglish
LHL446 Evidence of Coverage (Single Health Care Service Plan - Vision Care)
Checklist		 PDFEnglish
LHL550 Utilization Review Agent (URA)-HEALTH
Utilization Review Plan Summary Checklist		 PDFEnglish
LHL551 Utilization Review Agent (URA)-SPECIALTY
Utilization Review Plan Summary Checklist		 PDFEnglish
LHL552 Utilization Review Agent (URA)-WORKERS' COMPENSATION
Utilization Review Plan Summary Checklist		 PDFEnglish
LHL553 Utilization Review Agent (URA)-HEALTH & SPECIALTY
Appeal/Reconsideration Procedures Checklist		 PDFEnglish
LHL554 Utilization Review Agent (URA)-Health,Specialty & Workers' Compensation
Utilization Review Agent Complaint System Checklist		 PDFEnglish
LHL555 Utilization Review Agent (URA)-Workers' Compensation
Utilization Review Agent Appeal/Reconsideration Procedures Checklist		 PDFEnglish
LHL601 Notice of IRO Decision
IRO Decision Template-Health		 WORDEnglish
LHL602 Notice of IRO Decision
IRO Decision Template - Workers' Compensation		 WORDEnglish
LHL603 Notice of IRO Decision
IRO Decision Template - WC Network		 WORDEnglish
LHL652 Addendum to Biographical Affidavit
Addendum to Biographical Affidavit		 PDFEnglish
LHL654 Reconciliation of Benefits to Schedule of Charges
Reconciliation of Benefits to Schedule of Charges		 PDFEnglish
URBIOADD ADDENDUM TO BIOGRAPHICAL AFFIDAVIT
EXHIBIT 18		 PDFEnglish
LHL050 Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010
Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010-Revised date 06/09		 PDFEnglish
LHL050 Outline of Medicare Supplement Coverage
Outline of Coverage - Rev. 12/04		 PDFEnglish
LHL064 Life/Health Earned Premiums Credit Life Insurance
Collect data		 PDFEnglish
LHL065 Life/Health Actuarial Reserve Certification Form
Collect data		 PDFEnglish
LHL066 Life/Health Inventory Information Form Presumptive Rates
Collect data		 PDFEnglish
LHL069 Life/Health Inventory Information Form Deviated Rates
Collect data		 PDFEnglish
LHL071 Life/Health Affidavit of Validity of Experience Data Form
Collect data		 PDFEnglish
LHL072 Life/Health Earned Premiums Credit Disability Insurance
Collect data		 PDFEnglish
LHL073 Life/Health Reconciliation to State Page Credit Life
Collect data		 PDFEnglish
LHL074 Life/Health Reconciliation to State Page Credit Disability
Collect data		 PDFEnglish
LHL150 (Small Employer Carrier Status) Certification
 PDFEnglish
LHL152 Application to TDI (Risk-Assuming/Reinsured Carrier)
 PDFEnglish
LHL153 (Annual Listing-Exempt Forms & SEHBPs) Certification
 PDFEnglish
LHL154 Geographic Service Areas Certification
 PDFEnglish
LHL157 (Annual Actuarial) Certification To Texas Department of Insurance
 PDFEnglish
LHL158 Certification to Texas Department of Insurance
 PDFEnglish
LHL159 Report to Texas Department of Insurance (Private Purchasing Cooperatives) Statement of Amounts Collected and Expenses Incurred
 PDFEnglish
LHL160 (Large Employer Carrier Status) Certification TO Texas Department of Insurance Relating to Marketing in the Large Employer Market
 PDFEnglish
LHL161 Geographic Service Areas For Large Employer Carriers Certification To Texas Department of Insurance
 PDFEnglish
LHL187 Life/Health Open Records Request Form
Request for company information		 PDFEnglish
LHL235 Life/Health Credit Insurance Deviation Request Form
Deviation request form ( CI-DRF )		 PDFEnglish
LHL251 Life/Health Individual Indemnity Consumer Choice Benefit Plans
CCP Figure 1		 PDFEnglish
LHL253 Life/Health Group Indemnity Consumer Choice Benefit Plans
CCP Figure 1		 PDFEnglish
LHL258 Life/Health HGC-1, Health Group Cooperative-1 Annual Health Group Cooperatives Report to TDI
Statement of Amounts Collected and Expense Incurred		 PDFEnglish
LHL265 DISCRETIONARY GROUP CHECKLIST
Discrertionary Group Checklist		 PDFEnglish
LHL267 Life/Health Accident Only/AD&D Group
Group checklist		 PDFEnglish
LHL268 Life/Health Dental Group
Group checklist		 PDFEnglish
LHL269 Life/Health Disability/Business Overhead Expense
Group checklist		 PDFEnglish
LHL272 Life/Health Hospital Indemnity
Group checklist		 PDFEnglish
LHL280 Life/Health Specified Disease
Group checklist		 PDFEnglish
LHL281 Life/Health Stop Loss
Group checklist		 PDFEnglish
LHL282 Life/Health Supplemental Coverage
Group checklist		 PDFEnglish
LHL283 Life/Health Vision
Group checklist		 PDFEnglish
LHL284 Life/Health Large/Small Employer Group (includes Consumer Choice Health Benefit Plans)
Group checklist		 PDFEnglish
LHL285 Life/Health Long Term Care - Group
Group checklist		 PDFEnglish
LHL286 Life/Health Group Health Non-Employer or Member Association
Group checklist		 PDFEnglish
LHL287 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued
2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued - for Plans Sold for Effective dates on of after June 1, 2010		 PDFEnglish
LHL287 Life/Health Medicare Supplement/Medicare Select
Group checklist		 PDFEnglish
LHL293 Life/Health Accident Accidental Death & Dismemberment (AD&D)
Individual checklist		 PDFEnglish
LHL294 Life/Health Basic Hospital Expense, Basic Medical Surgical Expense, Combination Basic Hospital, Medical, Surgical Expense
Individual checklist 		PDFEnglish
LHL295 Life/Health Disability Income Protection
Individual checklist		 PDFEnglish
LHL296 Life/Health First Diagnosis
Individual checklist		 PDFEnglish
LHL298 Life/Health Hospital Indemnity
Individual checklist		 PDFEnglish
LHL299 Life/HealthLimited Benefit
Individual checklist		 PDFEnglish
LHL301 Life/Health Major Medical Expense
Individual checklist		 PDFEnglish
LHL304 Life/Health Specified Disease
Individual checklist		 PDFEnglish
LHL305 Life/Health Supplemental Coverage
Individual checklist		 PDFEnglish
LHL307 Group and Individual Long-Term Care Checklist
Group and individual checklists		 PDFEnglish
LHL308 2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued
2010 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued - for Plans Sold for Effective dates on of after June 1, 2010		 PDFEnglish
LHL308 Life/Health Medicare Supplement/Medicare Select
Individual checklists		 PDFEnglish
LHL314 Life/Health Individual Health Rate Filing Requirements
Individual checklist		 PDFEnglish
LHL315 Life/Health Annuity Applications
 PDFEnglish
LHL316 Life/Health Annuity Loan Provisions
 PDFEnglish
LHL317 Life/Health Annuities Used to Fund Structured Settlement Options
 PDFEnglish
LHL318 Life/Health Equity Indexed
Equity Indexed checklists		 PDFEnglish
LHL319 Life/Health Group Annuities Used as Funding Plans, Guaranteed Investment Contracts (GICs), and Synthetic GICs
 PDFEnglish
LHL320 Life/Health Guaranteed Living Benefit Endorsements/Provisions
 PDFEnglish
LHL321 Life/Health Individual and Group Deferred Annuities
 PDFEnglish
LHL323 Life/Health Single Premium Immediate Annuities
 PDFEnglish
LHL324 Life/Health Roth IRA Endorsements/Provisions
 PDFEnglish
LHL325 Life/Health SIMPLE IRA Endorsements/Provisions
 PDFEnglish
LHL326 Life/Health Guaranteed Minimum Death Benefit
 PDFEnglish
LHL327 Life/Health Variable Annuity Contracts
 PDFEnglish
LHL328 Life/Health Waiver of Surrender Charge Provisions/Riders on Disability/Confinement/Terminal Illness
 PDFEnglish
LHL335 Corporate Owned Life Insurance (COLI) - Individual
Checklist		 PDFEnglish
LHL336 Life/Health Corporate Owned Life Insurance (COLI) - Group
Checklist		 PDFEnglish
LHL337 Life/Health Extension of Maturity Date Beyond Age 100 or 121, As Applicable
Life insurance checklists		 PDFEnglish
LHL338 Life/Health Group Life Insurance
Life insurance checklists		 PDFEnglish
LHL339 Life/Health Individual Life Exclusion Riders
Life insurance checklists		 PDFEnglish
LHL341 Life/Health Individual Whole Life and Term Insurance Policies
Life insurance checklists		 PDFEnglish
LHL342 Life/Health Interest Sensitive Whole Life Policies
Life insurance checklists		 PDFEnglish
LHL343 Life/Health Life Applications
Life insurance checklists		 PDFEnglish
LHL344 Life/Health No-Lapse Guarantee Provisions
Life insurance checklists		 PDFEnglish
LHL346 Life/Health Universal Life Policies
Life insurance checklists		 PDFEnglish
LHL347 Life/Health Variable Life Insurance Policies
Life insurance checklists		 PDFEnglish
LHL348 Life/Health Reinstatement Due to Mental Incapacity
Life insurance checklists		 PDFEnglish
LHL349 Life/Health Individual Modified Guaranteed Investment Contracts Market Value Adjustment Provisions
 PDFEnglish
LHL350 Life/Health Life Illustration Certification and Notification
Life illustration filings		 PDFEnglish
LHL351 Life/Health Nonprofit Legal Services Contracts
Nonprofit legal services checklist		 PDFEnglish
LHL356 Life/Health Checklists for Assumption/Merger Certificates Life, Annuity and Credit/Accident and Health
 PDFEnglish
LHL366 Notice and Consent for HIV Testing
Consent Form		 PDFEnglish
LHL368 Actuarial Certification of Compliance with Chapter 1107, Texas Insurance Code, for Equity Indexed Annuities
Actuarial Certification		 PDFEnglish
LHL369 Initial Actuarial Certification of Compliance with Chapter 1107, Texas Insurance Code, for Equity Indexed Annuities
Initial Actuarial Certification		 PDFEnglish
LHL370 Additional Insured Benefit Riders Checklist
 PDFEnglish
LHL372 Family Term Riders Checklist
 PDFEnglish
LHL373 Consumer Price Index Riders Checklist
 PDFEnglish
LHL375 Substitute Insured Riders Checklist
 PDFEnglish
LHL376 WAIVER OF PREMIUM RIDERS - UNEMPLOYMENT
Life insurance checklists		 PDFEnglish
LHL377 Accidental Death Riders Checklist
 PDFEnglish
LHL378 ANNUALLY RENEWABLE TERM LIFE RIDERS
ANNUALLY RENEWABLE TERM LIFE RIDERS		 PDFEnglish
LHL379 Dependent Child Riders Checklist
 PDFEnglish
LHL384 Individual Health Outline of Coverage
Checklist		 PDFEnglish
LHL387 Credit Life and Credit Accident and Health Insurance Presumptive Premium Rates
Checklist		 PDFEnglish
LHL393 Funding Agreement/Well Plugging
Checklist		 PDFEnglish
LHL395 Paid-Up Additions Rider
Checklist		 PDFEnglish
LHL400 Accelerated Death Benefits
Checklist		 PDFEnglish
LHL401 Prepaid Funeral Insurance Policies/Contracts Checklist
 PDFEnglish
LHL402 Form Health Pool Notice
 PDFEnglish
LHL404 Return of Premium Checklist
Life insurance checklists		 PDFEnglish
LHL405 WAIVER OF PREMIUM/MONTHLY DEDUCTION RIDERS (Disability of Insured, Disability of Payor, Death of Payor, Nursing Home Confinement)
Life insurance checklists		 PDFEnglish
LHL406 Group Health Blanket Checklist
 PDFEnglish
LHL407 Employer Market Form Filing Checklist
 PDFEnglish
LHL413 Overloan Protection Provisions/Riders
Checklist		 PDFEnglish
LHL414 Fraternal Filings Checklist
 PDFEnglish
LHL415 Private Placement Filings Checklist
LHL415 Private Placement Filings Checklist 		PDFEnglish
LHL431 30-DAY FREE LOOK CHECKLIST
30-DAY FREE LOOK		 PDFEnglish
LHL560 Long-Term Care Insurance Personal Worksheet
LTC Personal Worksheet		 PDFEnglish
LHL561 Long-Term Care Insurance Potential Rate Increase Disclosure Form
LTC Potential Rate Increase 		PDFEnglish
LHL562 Long-Term Care Insurance Replacement and Lapse Reporting Form
Replacement and Lapse Reporting		 PDFEnglish
LHL563 Rescission Reporting Form for Long-Term Care Policies
LTC Rescission Reporting		 PDFEnglish
LHL564 Long-Term Care Insurance Claim Denials Reporting Form
LTC Claim Denials Reporting		 PDFEnglish
LHL565 Long-Term Care Policies Sold Reporting Form
LTC Policies Sold Reporting		 PDFEnglish
LHL566 Long-Term Care Suitability Reporting Form
LTC Suitability Reporting		 PDFEnglish
LHL567 Things To Know Before You Buy LTC Insurance
Things You Should Know Before You Buy 		PDFEnglish
LHL568 LTC Insurance Suitability Letter
Long-Term Care Insurance Suitability Letter		 PDFEnglish
LHL569 Partnership Status Disclosure Notice for LTC Partnership Policies/Certificates
Partnership Status Disclosure Notice		 PDFEnglish
LHL570 Long-Term Care Partnership Program Insurer Certification Form
LTC Partnership Program Insurer Certification 		PDFEnglish
LHL571 Long-Term Care Partnership Agent Training Certification
LTC Partnership Agent Training Certification		 PDFEnglish
LHL572 LTC Partnership Agent Training Certification Form
Long-Term Care Partnership Agent Training Certification Form		 PDFEnglish
LHL573 Insurer Certification of Association Compliance With Marketing Standards for LTC Partnership and Non-Partnership
Insurer Certification of Association Compliance With Marketing Standards for Long-Term Care Partnership and Non-Partnership Policies and Certificates		 PDFEnglish
LHL604 AGENT REPLACEMENT OF LIFE INSURANCE OR ANNUITIES NOTICE
 PDFEnglish
LHL605 COMPANY REPLACEMENT OF LIFE INSURANCE OR ANNUITIES NOTICE
 PDFEnglish
LHL606 NOTICE REPLACEMENT OF LIFE INSURANCE OR ANNUITIES
 PDFEnglish
LHL607 NONINSURANCE BENEFIT CHECKLIST
 PDFEnglish
LHL608 Health Benefit Plan/Provider Contracting Practices Survey
Health Benefit Plan Survey		 PDFEnglish
LHL609 Health Benefit Plan Issuer Hospital Grid
Health Benefit Plan Survey		 PDFEnglish
LHL610 Consumer Choice Health Benefit Plans Data Certification
CCP Figure 2		 PDFEnglish
LHL620 Credit Data Call Acknowledgment Receipt
Credit Data Call Acknowledgment Receipt for Years 2006, 2007 and 2008		 PDFEnglish
LHL621 INDIVIDUAL AND GROUP CREDIT LIFE AND CREDIT ACCIDENT AND HEALTH INSURANCE
Credit Life and Credit Accident and Health Checklist		 PDFEnglish
LHL651 OPTIONAL - Health Insurance Pools - Notice of Availability of Coverage under the Texas Health Insurance Pool or Under the Pre-Existing Condition Insurance Plan
OPTIONAL - Health Insurance Pools - Notice of Availability of Coverage under the Texas Health Insurance Pool or Under the Pre-Existing Condition Insurance Plan		 PDFEnglish
LHL653 Annuity Disclosure Checklist
 PDFEnglish
LHL203 Registration of Assumed Name/Branch Locations/Entity Name Change
Commonly known as form LDTL		 PDFEnglish
LHL367 Provider Renewal and Information Change Form
Application for Provider Renewal or Change of Contact Information.		 PDFEnglish
PC041 Texas Closed Claim Reporting Guide Order Form
Order form		 PDFEnglish
PC144 Texas Commercial Liability Closed Claim Report (Long Form)
Long Form - Indemnity Payments of $75,000 or More		 PDFEnglish
PC145 Texas Commercial Liability Closed Claim Report (Short Form)
Short Form - Indemnity Payments Over $25,000 But Less Than $75,000		 PDFEnglish
PC406 Request for Application - Appraisal Umpires
 PDFEnglish
PC407 Request for Application - Mediators
 PDFEnglish
PC136 Application for Appointment as Qualified Inspector
Requires notary and signature (aka Form ENG-1).		 PDFEnglish
PC321 Amusement Ride Certificate of Inspection/Reinspection
( Form AR-100 )		 PDFEnglish
PC321 Amusement Ride Certificate of Inspection/Reinspection
( Form AR-100 )		 WORDEnglish
PC322 Texas Amusement Ride Safety Inspection and Insurance Act Daily Inspection Record
( Form AR-300 )		 PDFEnglish
PC322 Texas Amusement Ride Safety Inspection and Insurance Act Daily Inspection Record
( Form AR-300 )		 WORDEnglish
PC323 Amusement Ride Schedule of Operations in Texas
( Form AR-102 )		 WORDEnglish
PC323 Amusement Ride Schedule of Operations in Texas
( Form AR-102 )		 PDFEnglish
PC324 Quarterly Injury Report Amusement Ride Safety Inspection and Insurance Act
( Form AR-800 )		 WORDEnglish
PC324 Quarterly Injury Report Amusement Ride Safety Inspection and Insurance Act
( Form AR-800 )		 PDFEnglish
PC325 Quarterly Governmental Action Report Amusement Ride Safety Inspection and Insurance Act
( Form AR-801 )		 PDFEnglish
PC325 Quarterly Governmental Action Report Amusement Ride Safety Inspection and Insurance Act
( Form AR-801 )		 WORDEnglish
PC350 Application for Windstorm Inspection Certificate of Compliance
Form WPI-1		 PDFEnglish
PC351 Inspection Verification Form
Form WPI-2-BC-1 (for projects that commenced construction between 1/1/1988 and 8/31/1998)		 PDFEnglish
PC352 Inspection Verification Form
Form WPI-2-BC-2 (for projects that commenced construction between 9/1/1998 and 1/31/2003)		 PDFEnglish
PC353 Inspection Verification Form
Form WPI-2-BC-3 (for projects that commenced construction between 2/1/2003 and 12/31/2004)		 PDFEnglish
PC354 Inspection Verification Form
Form WPI-2-BC-4 (for projects that commenced construction between 1/1/2005 and 12/31/2007)		 PDFEnglish
PC356 Proposed Change to Windstorm Building Requirements or Procedures in the TWIA Plan of Operation
A separate form must be submitted for each proposed change. 		WORDEnglish
PC356 Proposed Change to Windstorm Building Requirements or Procedures in the TWIA Plan of Operation
A separate form must be submitted for each proposed change.		 PDFEnglish
PC357 VIP Application for Residential Property Inspector License/Certificate
 WORDEnglish
PC357 VIP Application for Residential Property Inspector License/Certificate
 PDFEnglish
PC372 Certificate of Insurability (VIP1)
 WORDEnglish
PC372 Certificate of Insurability (VIP1)
 PDFEnglish
PC373 Residential Property Condition Evaluation Report (VIP2)
 PDFEnglish
PC373 Residential Property Condition Evaluation Report (VIP2)
 WORDEnglish
PC381 Public Information Notice for Amusement Rides
 WORDEnglish
PC381 Public Information Notice for Amusement Rides
 PDFEnglish
pc382 Inspection Verification Form
Form WPI-2-BC-5 (for projects that commenced construction on or after 1/1/2008)		 PDFEnglish
PC383 Loss Control Presentation Outline - Commercial Automobile/General Liability/Professional Liability for Insureds Other Than Hospitals
 WORDEnglish
PC383 Loss Control Presentation Outline - Commercial Automobile/General Liability/Professional Liability for Insureds Other Than Hospitals
 PDFEnglish
PC384 Loss Control Presentation Outline - Medical Professional Liability
 WORDEnglish
PC384 Loss Control Presentation Outline - Medical Professional Liability
 PDFEnglish
PC385 Loss Control Presentation Outline - Professional Liability for Hospitals
 WORDEnglish
PC385 Loss Control Presentation Outline - Professional Liability for Hospitals
 PDFEnglish
PC386 Commercial Automobile Liability Loss Control Information Worksheets
 WORDEnglish
PC386 Commercial Automobile Liability Loss Control Information Worksheets
 PDFEnglish
PC387 General Liability Loss Control Information Worksheets
 PDFEnglish
PC387 General Liability Loss Control Information Worksheets
 WORDEnglish
PC388 Professional Liability and Medical Professional for Hospitals Loss Control Information Worksheets
 WORDEnglish
PC388 Professional Liability and Medical Professional for Hospitals Loss Control Information Worksheets
 PDFEnglish
PC389 Qualification of Loss Control Representatives (LCRs) - Form 2
 PDFEnglish
PC389 Qualification of Loss Control Representatives (LCRs) - Form 2
 WORDEnglish
PC390 Loss Control Representative Qualification Review
 PDFEnglish
PC390 Loss Control Representative Qualification Review
 WORDEnglish
PC391 Field Safety Representative with a Specialty in Hospitals Qualification Review
 PDFEnglish
PC391 Field Safety Representative with a Specialty in Hospitals Qualification Review
 WORDEnglish
PC392 Outline of a Minimum Plan for a Loss Control Program
 WORDEnglish
PC392 Outline of a Minimum Plan for a Loss Control Program
 PDFEnglish
pc394 Design Certification
Form WPI-2D (for projects that will commence construction on or after 1/1/2008)		 PDFEnglish
PC397 Temporary Qualified Inspector Appointees Inspection Verification Modified Forms WPI-7 and WPI-2 (Between 10/01/2008 and 9/01/2009)
 PDFEnglish
PC399 Temporary Qualified Inspector Appointees Application of Compliance Modified Form WPI-1
 PDFEnglish
PC400 Contact Information Update Request
(To be completed by Appointed Qualified Inspectors only)		 PDFEnglish
PC053 Premium Reduction Certificate - Sprinkler
 PDFEnglish
PC053 Premium Reduction Certificate - Sprinkler
 WORDEnglish
PC068 Roofing Installation Information and Certification for Reduction in Residential Insurance Premiums
Reduction in Residential Insurance Premiums		 WORDEnglish
PC068 Roofing Installation Information and Certification for Reduction in Residential Insurance Premiums
Reduction in Residential Insurance Premiums		 PDFEnglish
PC317 Report of Inspector's Findings
Reduction in Residential Insurance Premiums		 WORDEnglish
PC317 Report of Inspector's Findings
Reduction in Residential Insurance Premiums		 PDFEnglish
PC326 Certificate of Mold Damage Remediation
Inspectors have to be licensed by the Texas Department of Health in order complete this form.		 WORDEnglish
PC326 Certificate of Mold Damage Remediation
Inspectors have to be licensed by the Texas Department of Health in order complete this form.		 PDFEnglish
PC327 Certificate of Applicance-Related Water Damage Remediation
 PDFEnglish
PC327 Certificate of Applicance-Related Water Damage Remediation
 WORDEnglish
PC328 El Declaración de Divulgación del Uso de Información de Crédito
 PDFEnglish
PC328 Use of Credit Information Disclosure
 PDFEnglish
PC120 Abstract Plant Information
 PDFEnglish
PC122 Title Insurance Agent's/Direct Operations Bond
 PDFEnglish
PC123 Escrow Officer's Schedule Bond
 PDFEnglish
PC129 Title Agent Update Form
 PDFEnglish
PC130 Application For Direct Operation License
 PDFEnglish
PC132 Application for Texas Escrow Officer's License
 PDFEnglish
PC132 Escrow Officer Application Addendum
Escrow Officer Application Addendum Regarding Fingerprint Processing and Electronic Fingerprint Procedures		 PDFEnglish
PC141 Agent Contract Submission Form
 PDFEnglish
PC142 Application for Additional Texas Title Insurance Agent's License
 PDFEnglish
PC143 Application for Texas Title Insurance Agent's License (Long Form)
 PDFEnglish
PC150 Report forms for Audit of Trust Funds
 PDFEnglish
PC314 Title Continuing Education Program New Provider Packet
 PDFEnglish
PC250 Deductible Notice of Election (DNE-1)
Selection of a deductible is not required. 		WORDEnglish
PC250 Deductible Notice of Election (DNE-1)
Selection of a deductible is not required.		 PDFEnglish
PC258 Group Purchase of Workers' Compensation Insurance Application for Certification of Group to Form
 WORD
PC258 Group Purchase of Workers' Compensation Insurance Application for Certification of Group to Form
 PDFEnglish
PC259 Group Purchase of Workers' Compensation Insurance Renewal Application for Certification for Group to Form
 WORD
PC259 Group Purchase of Workers' Compensation Insurance Renewal Application for Certification for Group to Form
 PDFEnglish
PC260 Request for Information (for Establishing Premiums)
Submit completed form to your insurance company.		 WORD
PC260 Request for Information (for Establishing Premiums)
Submit completed form to your insurance company.		 PDFEnglish
PC340 Certification of Sections 2251.251 - 2251.252
Exemption Compliance (EC-1)		 PDFEnglish
PC358 P&C Filing Transmittal Form
 PDFEnglish
PC359 Texas Addendum
to NAIC Property & Casualty Transmittal Form		 PDFEnglish
PC360 Company Certification
Mortgage Guaranty Rate Filings		 PDFEnglish
PC361 Credit Scoring Model Filing Form
 PDFEnglish
PC362 Certification of Sections 2251.201 - 2251.204
Exemption Compliance (EC-2)		 PDFEnglish
PC365 Exhibit C
Statewide Average Rate Level Information		 PDFEnglish
PC366 Exhibit D
Historical Experience		 PDFEnglish
PC367 Exhibit E
Expense Information - Including Disallowed Expense Adjustment 		PDFEnglish
PC368 Exhibit F
Expense Information - Other Than Lines Regulated Under Chapter 2251		 PDFEnglish
PC369 Exhibit G
Loss Costs Reference Information		 PDFEnglish
PC370 Exhibit H
Multi-Peril Rate Reference Information		 PDFEnglish
PC371 Exhibit L
Profit Provision Information 		PDFEnglish
PC374 Territory Exhibit
Display of Counties Affected by 15% Territory Rule		 PDFEnglish
PC375 CS Exhibit
Support for use of Credit Scoring		 PDFEnglish
PC376 Exhibit WC
Workers' Compensation		 PDFEnglish
PC377 Territory Exhibit
Support for Territorial Deviations		 PDFEnglish
PC404 Compliance Questionnaire - Use of Credit Information
 WORDEnglish
PC404 Compliance Questionnaire - Use of Credit Information
 PDFEnglish
PC405 CM Exhibit
Additional Information for Certain County Mutuals		 PDFEnglish
SF008 Forensic Arson Lab - Physical Evidence Submission Form
Form for submitting evidence to the State Fire Marshal's arson laboratory.		 PDFEnglish
SF009 Evidence Can Quality Check Form
Evidence Can Quality Check Form		 PDFEnglish
SF025 Fire Extinguisher Certificate of Registration Application
New Companies and New Branch Offices		 PDFEnglish
SF025 Fire Extinguisher Certificate of Registration Application
New Companies and New Branch Offices		 RTFEnglish
SF026 Fire Extinguisher License Application
 RTFEnglish
SF026 Fire Extinguisher License Application
 PDFEnglish
SF027 Fire Extinguisher Apprentice Permit Application
Fire Extinguisher Apprentice Permit Application		 PDFEnglish
SF027 Fire Extinguisher Apprentice Permit Application
Fire Extinguisher Apprentice Permit Application		 RTFEnglish
SF028 Fire Extinguisher Employee License Revision Application
 PDFEnglish
SF028 Fire Extinguisher Employee License Revision Application
 RTF
SF031 Fire Alarm Certificate of Registration Application
New Companies and New Branch Offices		 PDFEnglish
SF031 Fire Alarm Certificate of Registration Application
New Companies and New Branch Offices		 RTFEnglish
SF032 Fire Alarm License Application
 PDFEnglish
SF032 Fire Alarm License Application
 RTFEnglish
SF033 Revision/Transfer Application For All Types of Fire Alarm Licenses
 RTFEnglish
SF033 Revision/Transfer Application For All Types of Fire Alarm Licenses
 PDFEnglish
SF035 Fire Alarm Installation Certificate
 PDFEnglish
SF035 Fire Alarm Installation Certificate
 RTFEnglish
SF036 Fire Sprinkler Responsible Managing Employee (RME) License Application
 RTFEnglish
SF036 Fire Sprinkler Responsible Managing Employee (RME) License Application
 PDFEnglish
SF037 Fire Sprinkler Certificate of Registration Application
New Companies		 PDFEnglish
SF037 Fire Sprinkler Certificate of Registration Application
New Companies		 RTFEnglish
SF038 Sprinkler Change of Status Form
 PDFEnglish
SF038 Sprinkler Change of Status Form
 RTFEnglish
SF039 Abbreviated Requirements for Fire Sprinkler License and Registrations
 PDFEnglish
SF040 Sprinkler License & Test Information
 PDFEnglish
SF041 Contractor's Material and Test Certification for Above Ground Piping
 PDFEnglish
SF041 Contractor's Material and Test Certification for Above Ground Piping
 RTF
SF042 Contractor's Material and Test Certification for Underground Piping
 RTF
SF042 Contractor's Material and Test Certification for Underground Piping
 PDFEnglish
SF043 Application for Fireworks License and / or Permit
Distributors, Jobbers, Manufacturers, Wildlife, Agricultural and Industrial Permit		 RTFEnglish
SF043 Application for Fireworks License and / or Permit
Distributors, Jobbers, Manufacturers, Wildlife, Agricultural and Industrial Permit		 PDFEnglish
SF044 Application for Class B Fireworks Singular or Multiple Display Permit
 RTFEnglish
SF044 Application for Class B Fireworks Singular or Multiple Display Permit
 PDFEnglish
SF045 Pyrotechnic, Special Effects and Flame Effects Operator's License Application
 PDFEnglish
SF045 Pyrotechnic, Special Effects and Flame Effects Operator's License Application
 RTFEnglish
SF047 Application for Retail Fireworks Permit
 RTFEnglish
SF047 Application for Retail Fireworks Permit
 PDFEnglish
SF084 Renewal Application Fire Alarm Certificate of Registration
Renewal of companies and branch offices		 RTFEnglish
SF084 Renewal Application Fire Alarm Certificate of Registration
Renewal of companies and branch offices		 PDFEnglish
SF086 Renewal Application - Fire Extinguisher Certificate of Registration
Renewal of companies and branch offices		 RTFEnglish
SF086 Renewal Application - Fire Extinguisher Certificate of Registration
Renewal of companies and branch offices		 PDFEnglish
SF087 Renewal Application - Hydrostatic Testing Certificate of Registration
Renewal of companies and branch offices		 RTFEnglish
SF087 Renewal Application - Hydrostatic Testing Certificate of Registration
Renewal of companies and branch offices		 PDFEnglish
SF088 Renewal Application - Fire Sprinkler Certificate of Registration
Renewal of companies		 RTFEnglish
SF088 Renewal Application - Fire Sprinkler Certificate of Registration
Renewal of companies		 PDFEnglish
SF091 Renewal Application - Fireworks License
Distributors, Jobbers, Manufacturers		 PDFEnglish
SF091 Renewal Application - Fireworks License
Distributors, Jobbers, Manufacturers		 RTFEnglish
SF094 Renewal Application Fire Alarm Individual License
 PDFEnglish
SF094 Renewal Application Fire Alarm Individual License
 RTFEnglish
SF099 Renewal Application - Fire Extinguisher License
Renewal of companies and branch offices		 RTFEnglish
SF099 Renewal Application - Fire Extinguisher License
Renewal of companies and branch offices		 PDFEnglish
SF100 Renewal Application - Fire Sprinkler Responsible Managing Employee
 RTFEnglish
SF100 Renewal Application - Fire Sprinkler Responsible Managing Employee
 PDFEnglish
SF104 Renewal Application - Fireworks Operator's License
 RTFEnglish
SF104 Renewal Application - Fireworks Operator's License
 PDFEnglish
SF205 Fire Extinguisher System Installation Certification
 PDFEnglish
SF222 Retail Fireworks Indoor Site Information Form
 PDFEnglish
SF222 Retail Fireworks Indoor Site Information Form
 RTFEnglish
SF223 Fireworks Incident Report Form
A form to assist licensees and permitees in reporting an unauthorized fireworks explosion as required by 28TAC §34.819(d) and (c).		 RTFEnglish
SF223 Fireworks Incident Report Form
A form to assist licensees and permitees in reporting an unauthorized fireworks explosion as required by 28TAC §34.819(d) and (c).		 PDFEnglish
SF224 Licensing Investigation Complaint Form
A convenient form to use by anyone to report a suspected licensing violation to the SFMO.		 PDFEnglish
SF224 Licensing Investigation Complaint Form
A convenient form to use by anyone to report a suspected licensing violation to the SFMO.		 RTFEnglish
SF227 File Update Form
To update company address and authorized signatures		 PDFEnglish
SF227 File Update Form
To update company address and authorized signatures		 RTFEnglish
SF228 Licensed Employee Termination Notice
 PDFEnglish
SF228 Licensed Employee Termination Notice
 RTFEnglish
SF229 Fire Alarm License & Test Information
 PDFEnglish
SF234 Fire Extinguisher License and Test Information
 PDFEnglish
SF238 Fireworks License & Test Information
 PDFEnglish
SF239 Insurance Requirements
 RTFEnglish
SF239 Insurance Requirements
 PDFEnglish
SF242 Fire Drill Exit Report 2011-2012
2011-2012		 PDFEnglish
SF243 Contacts for Requesting a Criminal History Report
 RTFEnglish
SF243 Contacts for Requesting a Criminal History Report
 PDFEnglish
SF245 Abbreviated Guide to Obtain a “Specialized” License and Registration to Install Underground Fire Sprinkler Mains
 PDFEnglish
SF250 Fire Standard Compliant Cigarette Manufacturer Form
Certification by Manufacturer		 PDFEnglish
SF251 Fire Standard Compliant Cigarette Manufacturer Form
Application for Fire Standard Compliant Cigarette Marking Approval		 PDFEnglish
sf252 Fire Standard Compliant Cigarettes Complaint Form
fire standard compliant cigarettes complaint form		 RTFEnglish
SF252 Fire Standard Compliant Cigarettes Complaint Form
Fire Standard Compliant Cigarettes Complaint Form		 PDFEnglish
SF256 Texas Fire & Life Safety Educators
Website and Database Permission Form		 PDFEnglish
SF257 TXFLSE E-Group
 PDFEnglish


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