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You are here: Home . forms . formlisting

Listing of All Texas Department of Insurance Forms

Forms - NAIC

Listing of All Texas Department of Insurance Forms
TDI Form Number Description File FormatLanguage
AH001
Group Health Product Requirements Checklist
PDF English
AH002
Group Health Large and Small Employer Requirements Checklist
PDF English
AH003
Group Health Non-Employer or Member Association Checklist
PDF English
AH004
Group Health Accident Only/Accidental Death and Dismemberment (AD&D) Checklist
PDF English
AH005
Group Health Discretionary Group Checklist
PDF English
AH006
Group Blanket Accident and Health Checklist
PDF English
AH007
Group Health Disability / Business Overhead Expense Checklist
PDF English
AH008
Group Health Employer Market Form Filing Checklist - Figure 40, 42, 43, 47, 48, and 50
PDF English
AH009
Group Health Specified Disease Checklist
PDF English
AH010
Group Health Stop Loss Checklist
PDF English
AH011
Group and Individual Dental and Vision Checklist
PDF English
AH012
Group and Individual Long-Term Care Checklist
PDF English
AH013
Group and Individual Health Supplemental Coverage Checklist
PDF English
AH014
Group and Individual Health Medicare Supplement and Select Checklist
PDF English
AH015
Individual Health Product Requirements Checklist
PDF English
AH016
Individual Health Major Medical Checklist
PDF English
AH017
Individual Health Limited Benefit Checklist
PDF English
AH018
Individual Health Accident Only / Accidental Death and Dismemberment (AD&D) Checklist
PDF English
AH019
Individual Health Basic Hospital or Medical-Surgical Expense, Combination Basic Hospital, Medical, Surgical Expense Checklist
PDF English
AH020
Individual Health First Diagnosis or Critical Illness and Specified Disease Checklist
PDF English
AH021
Individual Health Rate / Rate Increase Filing Requirements Checklist
PDF English
AH022
Individual and Group Health Disability Income Protection Checklist
PDF English
AH023
Individual and Group Health Hospital Indemnity Checklist
PDF English
AH024
Individual Short-Term Recovery Care Checklist
PDF English
AS004
Accounting Texas Overhead Assessment
PDF English
AS044
Insurance Agent /Agency Order Form
PDF English
sf054
Branch Office List For Renewal
PDF English
CP003
TDI Speakers Bureau Request Form
PDF English
CP012
Complaint Form
File an insurance complaint.
PDF English
CP012S
Formulario de Queja
PDF Spanish
CP029
Health Insurance Mediation Request Form
Request health insurance mediation
PDF English
CP030
Life Policy Locator Service Consumer Request Form
PDF English
CP030S
Servicio para la Localización de una Póliza de Vida Formulario de Solicitud del Consumidor
PDF Spanish
CP031
Important Information You Should Know Before Entering Into a Life Settlement
Important Information You Should Know Before Entering Into a Life Settlement
PDF English
DWC001
Employer's First Report of Injury or Illness
Rev. 10/05. This form is submitted by the carrier to DWC.
PDF English
DWC001S
Employer's First Report of Injury or Illness (for state employees)
Rev. 10/05
PDF English
DWC002
Employer's Report for Reimbursement of Voluntary Payment
Rev. 02/17
PDF English
DWC003
Employer's Wage Statement
Rev. 10/05
PDF English
DWC003ME
Employee's Multiple Employment Wage Statement
Rev. 04/16
PDF English
DWC003MES
Declaración de Salario de Múltiples Trabajos del Empleado
Rev. 04/16
PDF Spanish
DWC003S
Declaración de Salario del Empleador
Rev. 10/05
PDF Spanish
DWC003SD
Employer's Wage Statement for School Districts
Rev. 10/05
PDF English
DWC003SDS
Declaración de Salario Para Escuelas de Distrito
Rev. 10/05
PDF Spanish
DWC004
Employer's Contest of Compensability
Rev. 11/08
PDF English
DWC005
Indicates forms available for electronic filing
Employer Notice of No Coverage or Termination of Coverage
Rev. 01/13 - For help and an instructional video see “Electronic Filing - Online Forms” above.
PDF English
DWC005
Employer Notice of No Coverage or Termination of Coverage
Rev. 1/13 - static version for mailing and faxing
PDF English
DWC006
Supplemental Report of Injury
Rev. 10/05
PDF English
DWC007
Employer’s Report of Non-covered Employee’s Occupational Injury or Disease
Rev. 01/13
PDF English
DWC008
Return-to-Work Reimbursement Program for Employers
Rev. 04/10
WORD English
DWC008
Return-to-Work Reimbursement Program for Employers
Rev. 04/10
PDF English
DWC020
Insurance Carrier's Notice of Coverage/Cancellation/Non-Renewal of Coverage
Rev. 10/05
PDF English
DWC020A
Correction/Revision/Endorsement to Existing Policy
Rev. 10/05
PDF English
DWC020SI
Indicates forms available for electronic filing
Self-Insured Governmental Entity Coverage Information
Rev. 08/12 - Using Google Chrome or Mozilla Firefox to file electronically? See more at “Electronic Filing - Online Forms” above.
PDF English
DWC022
Required Medical Examination (RME) - Request for Agreement / Request for Order
Rev. 7/11
PDF English
DWC022S
Examen Médico Requerido (Required Medical Examination –RME, por su nombre y siglas en inglés) – Solicitud para un Acuerdo / Solicitud para una Orden
PDF Spanish
DWC024
Benefit Dispute Agreement
Rev. 03/17
PDF English
DWC024s
Acuerdo para Disputa de Beneficios
Rev. 03/17
PDF Spanish
DWC025
Benefit Dispute Settlement
Rev. 02/17
PDF English
DWC025s
Acuerdo por Disputa de Beneficios
Rev. 02/17
PDF Spanish
DWC026
Request for Reimbursement of Payment Made by Health Care Insurer
Rev. 01/15
PDF English
DWC027
Designation of Insurance Carrier’s Austin Representative
Rev. 12/11
PDF English
DWC030
Austin Representative’s Authorized Designees
Rev. 12/11
PDF English
DWC031
Application for Division Approval of Change in the Payment Period and/or Purchase of an Annuity for Death Benefits
Rev. 02/17
PDF English
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. 02/17
PDF Spanish
DWC032
Request for Designated Doctor Examination
Rev. 1/13
PDF English
DWC032S
Solicitud para Obtener un Examen por Parte de un Médico Designado
Rev. 1/13
PDF Spanish
DWC033
Carrier's Request for Reduction of Income Benefits Due to Contribution
Rev. 02/17
PDF English
DWC035
Application for Division Approval of the Purchase of an Annuity for Lifetime Income Benefits
Rev. 02/17
PDF English
DWC041
Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease
Rev. 3/07
PDF English
DWC041
Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease
Rev. 3/07
WORD English
DWC041S
Reclamo del Empleado para Compensación por una Lesión Relacionada con el Trabajo o Enfermedad Ocupacional
Rev. 3/07
PDF Spanish
DWC041S
Reclamo del Empleado para Compensación por una Lesión Relacionada con el Trabajo o Enfermedad Ocupacional
Rev. 3/07
WORD Spanish
DWC042
Claim for Workers’ Compensation Death Benefits
Rev. 03/16
PDF English
DWC042
Claim for Workers’ Compensation Death Benefits
Rev. 03/16
WORD English
DWC042S
Reclamación para Obtener Beneficios de Compensación para Trabajadores por Causa de Muerte
Rev. 3/16
PDF Spanish
DWC042S
Reclamación para Obtener Beneficios de Compensación para Trabajadores por Causa de Muerte
Rev. 3/16
WORD Spanish
DWC044
Election to Engage in Arbitration
Rev. 06/12
PDF English
DWC044S
Elección para Participar en un Arbitraje
Rev. 06/12
PDF Spanish
DWC045
Request to Schedule, Reschedule, or Cancel a Benefit Review Conference (BRC), or to Proceed Directly to Contested Case Hearing (CCH)
Rev. 07/17
PDF English
DWC045A
Request for a Medical Contested Case or SOAH Hearing
Rev. 09/07, applicable only to medical disputes that were filed prior to June 1, 2012
PDF English
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, aplicable solamente para las disputas médicas que fueron presentadas antes del 1º de junio del 2012
PDF Spanish
DWC045S
Solicitud para Programar, Reprogramar, o Cancelar una Conferencia para Revisión de Beneficios (Benefit Review Conference–BRC), o para Proceder Directamente a una Audiencia para Disputar Beneficios (Contested Case Hearing–CCH)
Rev. 07/17
PDF Spanish
DWC045M
Request to Schedule, Reschedule, or Cancel a Benefit Review Conference to Appeal a Medical Fee Dispute Decision (BRC-MFD)
Rev. 02/17
PDF English
DWC045MS
Solicitud para Programar, Reprogramar, o Cancelar una Conferencia para Revisión de Beneficios para Apelar la Decisión de una Disputa por Honorarios Médicos
Rev. 02/17
PDF Spanish
DWC046
Employee's Request for Acceleration of Impairment Income Benefits
Rev. 02/17
PDF English
DWC046S
Solicitud del Trabajador Lesionado para Recibir un Pago Acelerado de Beneficios por Causa del Impedimento Corporal
Rev. 02/17
PDF Spanish
DWC047
Employee’s Request for Advance of Benefits
Rev. 02/17
PDF English
DWC047S
Solicitud del Empleado para Obtener Beneficios por Adelantado
Rev. 02/17
PDF Spanish
DWC048
Request to Get Reimbursed for Travel Costs
Rev. 02/17
PDF English
DWC048S
Solicitud para Obtener un Reembolso por Gastos de Viaje
Rev. 02/17
PDF Spanish
DWC049
Request to Schedule a Medical Contested Case Hearing (MCCH)
Rev. 02/17
PDF English
DWC049S
Solicitud para Programar una Audiencia para Disputar Beneficios Médicos (Medical Contested Case Hearing –MCCH, por su nombre y siglas en inglés)
Rev. 02/17
PDF Spanish
DWC051
Employee's Election for Commuted (Lump Sum) Impairment Income Benefits
Rev. 02/17
PDF English
DWC051S
Elección del Empleado para la Conversión de los Beneficios de Ingresos de Impedimento a un Pago Total
Rev. 02/17
PDF Spanish
DWC052
Application for Supplemental Income Benefits
Rev. 02/17
PDF English
DWC052S
Aplicación del trabajador para beneficios de ingresos suplementales
Rev. 02/17
PDF Spanish
DWC053
Employee Request to Change Treating Doctor
Rev. 03/12
PDF English
DWC053S
Solicitud del Empleado para Cambiar de Médico de Tratamiento
Rev. 03/12
PDF Spanish
DWC054
Notice to Employee: Intention to Request Division Permission to Adjust Benefits
Rev. 02/17
PDF English
DWC054S
Aviso al/a la Empleado/a: Intencion de Solicitar permiso a la División para Ajuste de Beneficios
Rev. 02/17
PDF Spanish
DWC055
Request to Adjust Average Weekly Wage for Seasonal Employee
Rev. 02/17
PDF English
DWC055S
Solicitud de Ajuste al Salario Medio Semanal de un(a) Empleado/a de Temporada
Rev. 02/17
PDF Spanish
DWC056
Carrier's Request for Seasonal Employee Wage Information from Texas Workforce Commission Records
Rev. 02/17
PDF English
DWC057
Request for Extension of Maximum Medical Improvement Date for Spinal Surgery
Rev. 02/17
PDF English
DWC057S
Solicitud para Extensión de la Fecha para el Mejoramiento Máximo Médico (Maximum Medical Improvement -MMI, por su nombre y siglas en inglés) por una Cirugía de la Columna Vertebral
Rev. 02/17
PDF Spanish
DWC058
Request for Interlocutory Order
Rev. 09/07
PDF English
DWC060
Medical Fee Dispute Resolution Request
Rev. 06/12
PDF English
DWC060S
Solicitud para Resolución de Disputas por Honorarios Médicos
Rev. 06/12
PDF Spanish
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
PDF English
DWC065
Application for Inclusion on Registry of Private Providers of Vocational Rehabilitation Services
Rev. 1/11
PDF English
DWC066
Statement of Pharmacy Services
Rev. 12/11
PDF English
DWC067
Designated Doctor Certification Application
Rev. 8/16 - for use on or after 9/1/16
PDF English
DWC068
Designated Doctor Examination Data Report
Rev. 2/17
PDF English
DWC069
Report of Medical Evaluation
Rev. 1/15 (for use on or after 1/1/15)
PDF English
DWC070
Instructions For Completing The ADA J515 Dental Claim Form For Texas Workers' Compensation Claims
Rev. 10/05
PDF English
DWC072
Medical Quality Review Panel Application
Rev. 01/13
PDF English
DWC073
Work Status Report
Rev. 02/11
PDF English
DWC074
Description of Injured Employee’s Employment
Rev. 9/09
PDF English
DWC081
Agreement Between General Contractor and Sub-Contractor to Provide Worker's Compensation Insurance
Rev. 10/05
PDF English
DWC081S
Acuerdo Entre el Contratista General y el Sub Contratista
Rev. 09/07
PDF Spanish
DWC082
Agreement for Motor Carriers and Owner Operators
Rev. 10/05
PDF English
DWC083
Agreement for Certain Building and Construction Workers
Rev. 10/05
PDF English
DWC083S
Acuerdo para Ciertos Trabajadores de Edificación y Construcción
Rev. 09/06
PDF Spanish
DWC084
Exception to Application of Joint Agreement for Certain Building and Construction Workers
Rev. 10/05
PDF English
DWC085
Agreement Between General Contractor and Subcontractor to Establish Independent Relationship
Rev. 10/05
PDF English
DWC085S
Acuerdo Entre el Contratista General y el Sub Contratista Para Establecer una Relación Independiente
Rev. 11/06
PDF Spanish
DWC101
Program Review Report
Rev. 08/06
PDF English
DWC101
Program Review Report
Rev. 08/06
WORD English
DWC102
Accident Prevention Plan Cover Sheet
Rev. 08/06
PDF English
DWC102
Accident Prevention Plan Cover Sheet
Rev. 08/06
WORD English
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.
WORD English
DWC104
Employer Request for DWC Safety Consultation
Rev. 08/06
PDF English
DWC104
Employer Request for DWC Safety Consultation
Rev. 08/06
WORD English
DWC105
Accident Prevention Services Worksheet
Rev. 10/13
PDF English
DWC105
Accident Prevention Services Worksheet
Rev. 10/13
WORD English
DWC105
Accident Prevention Services Worksheet
Rev. 10/13
PDF English
DWC105
Accident Prevention Services Worksheet
Rev. 10/13
WORD English
DWC109
Accident Prevention Services Annual Report
Rev. 10/13
PDF English
DWC109
Accident Prevention Services Annual Report
Rev. 10/13
WORD English
DWC109
Accident Prevention Services Annual Report
Rev. 10/13
PDF English
DWC109
Accident Prevention Services Annual Report
Rev. 10/13
WORD English
DWC150
Notice of Representation
Rev. 12/16
PDF English
DWC150A
Notice of Withdrawal of Representation
Rev. 12/16
PDF English
DWC150AS
Aviso de Anulación de Representación Legal
Rev. 12/16
PDF Spanish
DWC150S
Aviso de Representación Legal
Rev. 12/16
PDF Spanish
DWC151
Attorney Application for Web Access
Rev. 12/16
PDF English
DWC152
Application for Attorney Fees
Rev. 12/16
PDF English
DWC153
Request for Copies of Confidential Claimant Information
Rev. 10/06
PDF English
DWC153s
Solicitud para Obtener Copias de la Información Confidencial del Reclamante
Rev. 07/08
PDF English
DWC154
Workers' Compensation Complaint Form
Rev. 03/16
PDF English
DWC154S
Quejas de Compensación para Trabajadores
Rev. 03/16
PDF Spanish
DWC155
Request for Record Check
Rev. 10/05
PDF English
DWC156
Prospective Employment Authorization and Certification
Rev. 10/05
PDF English
DWC156S
Certificación Y Autorización De Un Posible Empleo
Rev. 10/06
PDF Spanish
DWC205
Locations of Employer’s Business(es)
Addendum to DWC Form-005 or DWC Form-020 - Rev. 11/10
PDF English
DWC205S
Locaciones del Negocio(s) del Empleador
Suplemento para el Formulario DWC005 o Formulario DWC020 - Rev. 11/10
PDF Spanish
DWC210
Surety Bond for Certified Self-Insurance Liabilities
Rev. 1/06
PDF English
DWC210
Surety Bond for Certified Self-Insurance Liabilities
Rev. 1/06
WORD English
DWC215
Surety Bond Amount Rider
Rev. 1/06
PDF English
DWC215
Surety Bond Amount Rider
Rev. 1/06
WORD English
DWC216
Surety Bond Name Change Rider
Rev. 1/06
PDF English
DWC216
Surety Bond Name Change Rider
Rev. 1/06
WORD English
DWC223
Documentary Irrevocable Standby Letter of Credit
Rev. 01/07
PDF English
DWC223
Documentary Irrevocable Standby Letter of Credit
Rev. 01/07
WORD English
DWC224
Documentary Irrevocable Standby Letter of Credit (Confirmation)
Rev. 01/07
PDF English
DWC224
Documentary Irrevocable Standby Letter of Credit (Confirmation)
Rev. 01/07
WORD English
DWC225
Self-Insurer's Agreement to Post Documentary Irrevocable Standby Letter of Credit
Rev. 01/07
PDF English
DWC225
Self-Insurer's Agreement to Post Documentary Irrevocable Standby Letter of Credit
Rev. 01/07
WORD English
DWC226
Parental Guaranty
Rev. 01/07
PDF English
DWC226
Parental Guaranty
Rev. 01/07
WORD English
DWC227
Parental Guaranty for Less than Wholly Owned Subsidiary
Rev. 01/07
PDF English
DWC227
Parental Guaranty for Less than Wholly Owned Subsidiary
Rev. 01/07
WORD English
DWC228
Power of Attorney
Rev. 01/07
PDF English
DWC228
Power of Attorney
Rev. 01/07
WORD English
DWC230
Surety Bond for Assumed Certified Self-Insurance Liabilities
Rev. 03/14
PDF English
DWC230
Surety Bond for Assumed Certified Self-Insurance Liabilities
Rev. 03/14
WORD English
EDI-01
EDI Trading Partner Profile
Rev. 10/16
PDF English
EDI-02
Insurance Carrier or Trading Partner Medical Electronic Data Interchange (Edi) Profile
Rev. 10/16
PDF English
EDI-03
Medical EDI Compliance Coordinator and Trading Partner Notification
Rev. 10/16
PDF English
FIN111
Health Entities NAIC Checklist
Health Filing Requirements NAIC Checklist
PDF English
FIN116
HMO Supplement - Annual Information
PDF English
FIN117
TDI Instructions for Filing CPA Audited Financial Reports
PDF English
FIN119
Life, Accident and Health Insurers NAIC Checklist
Life, Accident and Health Insurers Filing Requirements NAIC Checklist
PDF English
FIN122
Property & Casualty Insurers NAIC Checklist
Property & Casualty Insurers Filing Requirements NAIC Checklist
PDF English
FIN123
TDI Supplement Form for County Mutuals
PDF English
FIN126
Fraternal Benefit Societies NAIC Checklist
Fraternal Benefit Societies Filing Requirements NAIC Checklist
PDF English
FIN127
Title Insurers NAIC Checklist
Title Insurers Filing Requirements NAIC Checklist
PDF English
FIN128
Annual Statement Blank - Farm Mutual Companies
EXCEL English
FIN128
Annual Statement Blank - Farm Mutual Companies
PDF English
FIN129
Prepaid Legal Services Corporation Annual Statement
Annual Statement Blank - Prepaid Legal Companies
EXCEL English
FIN129
Prepaid Legal Services Corporation Annual Statement Blank
Annual Statement Blank - Prepaid Legal Companies
PDF English
FIN138
Texas Supplemental A for County Mutuals Form
Texas Supplemental "A" for County Mutuals Form
PDF English
FIN139
Annual Operations Report
Form required to be filed annually by premium finance company, due April 1.
PDF English
FIN145
Guidelines and Application for Approval to Maintain Books and Records Outside of Texas
PDF English
FIN150
Texas Negotiated Deductible Workers' Compensation Form
PDF English
FIN160, PF1
Application for An Insurance Premium Finance Company License (Form PF1)
Premium Finance application for initial license to operate in Texas
PDF English
FIN161, PF1A
Supplemental Application for a Premium Finance Company (Form PF1A)
Form premium finance company completes to notify TDI of changes, such as an additional location, relocation, name change and/or ownership change
PDF English
FIN162, PF1B
Application for an Insurance Premium Finance License by a Bank or Savings and Loan Association (Form PF1B)
Application for a bank or savings and loan to be a licensed premium finance company
PDF English
FIN163, PF1C
Premium Finance Renewal Application (Form PF1C)
Premium Finance Renewal Application Form, required if renewing or not renewing
PDF English
FIN164, PF2
Premium Finance List of Principals
List all officers, directors and contact persons of Premium Finance Company
PDF English
FIN165, PF3
Questionnaire - Premium Finance Applicant (Form PF3)
Questionnaire to be completed by those wishing to obtain a premium finance company license
PDF English
FIN166, PF4
Biographical Affidavit - Premium Finance Applicant (Form PF4)
Form to be completed by each individual named on Form PF2.
PDF English
FIN167, PF5
List of Other States of Licensure - Premium Finance Applicant (Form PF5)
List of other states where Premium Finance Company is licensed
PDF English
FIN168, PF6
Appointment of Statutory Agent and Consent to Service - Premium Finance Applicant (Form PF6)
Form to be completed by premium finance company, appointing statutory agent for service of process who resides in the state of Texas
PDF English
FIN169, PF7
Premium Finance Premium Comparison Disclosure Form
Disclosure form/notice regarding interest charges incurred when purchasing liability insurance through the Texas Automobile Insurance Plan Association (TAIPA), if paid through a monthly installment plan.
PDF English / Spanish
FIN170, PF Schedule A
Filings Required for Premium Finance Application for Additional Location (Schedule A)
Checklist outlining the documents required when Premium Finance Company is adding a location
PDF English
FIN171, PF Schedule B
Filings Required for Premium Finance Application for Relocation (Schedule B)
Checklist outlining documents required when a Premium Finance Company is relocating
PDF English
FIN172, PF Schedule C
Filings Required for Premium Finance Application for Name Change (Schedule C)
Checklist outlining documents required for a Premium Finance Company to change its name
PDF English
FIN173, PF Schedule D
Filings Required for Premium Finance Application for Change of Ownership (Schedule D)
Checklist outlining requirements for Premium Finance Company to change ownership
PDF English
FIN179
Guidelines for the formation of a Texas Captive Insurance Company
Guidelines for the formation of a Texas Captive Insurance Company
PDF English
FIN180
Certificate of Authority Application for a Captive Insurance Company
Certificate of Authority Application for a Captive Insurance Company, either a Texas start up or a company wishing to redomesticate to Texas
PDF English
FIN181
Biographical Affidavit for Captive Insurance Company
Biographical Affidavit form for individuals that oversee management of the Captive Insurance Company
PDF English
FIN182
Financial Projections for Captive Insurance Company
Financial Projections Excel Workbook for Captive Insurance Company
EXCEL English
FIN183
Guidelines for captive insurance company who wishes to relocate to Texas, including optional pre-filing process.
Redomestication Guidelines for Captive Insurance Companies
PDF English
FIN184
Appointment of Agent for Service of Process for a Captive Insurance Company
Notarized form appointing an agent for service of process for a captive insurance company
PDF English
FIN185
Moving a Captive Insurance Company's Books and Records Out of the State of Texas Under Texas Insurance Code, Section 803
Form and requirements for a captive insurance company wishing to move its books, records, accounts, and/or principle office(s) outside the state of Texas
PDF English
FIN186
Captive Insurance Company Officers' Certification and Attestation Certificate of Filing
Certification by a Captive Insurance Company's Officers in regards to true and accurate information submitted with application
PDF English
FIN202
Texas Policyholder Dividend Disbursement Notification/Application
FIN 202 Texas Policyholder Dividend Disbursement Notification Application
PDF English
FIN244
CPA Audited Financial Report - Intent Form
Register a CPA to file an audited financial report
PDF English
FIN245A
Attachment 1A: Application Form
Legal Entities
PDF English
FIN245B
Attachment 1B: Application Form
Individuals
PDF English
FIN246
Affidavit for Exemption from Filing CPA Audited Financial Report
CPA Exemption Form
PDF English
FIN251
Annual Statement Blank - Mutual Assessments, LMA's, Burials
EXCEL English
FIN251
Annual Statement Blank - Mutual Assessments, Burials, LMAs
PDF English
FIN252
HMO Quarterly Supplement
PDF English
FIN300
Company Name Application
Application to reserve a company name
PDF English
FIN302
HMO Application for Certificate of Authority
Application for an HMO to do business in the state of Texas
PDF English
FIN306
Officers and Directors Page
Complete Listing of all Current Officers and Directors
PDF English
FIN307
Attorney-in-Fact and Underwriters Page
Lists the Attorney-in-Fact and Underwriters of Lloyds and Reciprocals
PDF English
FIN310
Application For A License As An Advisory Organization
Submit application to be licensed as an Advisory Organization
PDF English
FIN311
Biographical Affidavit
Biographical Affidavit form to be completed by certain officers and directors of insurance companies; compliance with statute
PDF English
FIN312
Attorney for Service form
Attorney for Service form
PDF English
FIN321
Company Licensing Fee Transmittal Form
Company Licensing and Registration Fee Transmittal Form to be submitted with filings.
PDF English
FIN322
Articles of Incorporation for a Texas Domestic P&C Company
Submitted as Articles of Incorporation for a Texas Domestic Property and Casualty Company
PDF English
FIN323
Articles of Incorporation for a Texas Domestic Life, Health and Accident Company
Submitted as Articles of Incorporation for a Texas Domestic Life, Health and Accident Company
PDF English
FIN324
Biographical Affidavit Update
submitted as notification of changes to biographical affidavit
PDF English
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
PDF English
FIN332
Articles of Incorporation Amendments for Texas Stock Property and Casualty or Life, Health and Accident Insurance Companies
Amendments to Articles of Incorporation for Texas Domestic Company
PDF English
FIN341
Merger Checklist
Checklist for filing a merger between two stock insurance companies where at least one of the companies is domiciled in Texas
PDF English
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
PDF English
FIN346
Checklist for Total and Partial Reinsurance Agreements Involving Foreign Insurance Companies
Checklist for Total or Partial Assumption Reinsurance Agreements involving two foreign insurance companies
PDF English
FIN349
Withdrawal Checklist
Filing instruction for an insurer wanting to withdraw or cease writing a line or lines of insurance in the state of Texas
PDF English
FIN350
Guidelines to Re-enter Texas Market Subsequent to Withdrawal
Filing instruction for insurance companies wishing to re-enter the Texas insurance market subsequent to filing a withdrawal plan
PDF English
FIN351
Voluntary Dissolution Checklist
Instructions for a Texas-Domestic Company wanting to Dissolve and Cancel its Certificate of Authority
PDF English
FIN352
CCRC Biographical Affidavit Requirements
Biographical afffidavit requirements for Continuing Care Retirement Communities (CCRCs)
PDF English
FIN353
Biographical Affidavit and Fingerprint Requirements for Texas-Domestic Insurers
Requirements and instructions for submitting biographical affidavits and fingerprints for Texas-domestic insurers
PDF English
FIN354
Biographical Affidavit and Fingerprint Requirements for Foreign Insurers
Instructions and requirements for submitting biographical affidavit and fingerprints for foreign insurers
PDF English
FIN355
Biographical Affidavit and Fingerprint Requirements for Health Maintenance Organizations (HMOs)
Instructions and requirements for submitting biographical affidavit and fingerprints for Health Maintenance Organizations (HMOs)
PDF English
FIN356
Biographical Affidavit and Fingerprint Requirements for Texas Lloyds and Reciprocal Insurers
Instructions and requirements for submitting biographical affidavit and fingerprints for Texas Lloyds and Reciprocal insurers
PDF English
FIN357
HMO Certificate of Authority Application Checklist
Filing instructions for an entity wishing to do business as a Health Maintenance Organization (HMO) in Texas
PDF English
FIN358
HMO DBA Filing Checklist
Filing instructions relating to an HMO's DBA, Assumed Name, Trade Mark, Service Marks and Logos
PDF English
FIN359
HMO Home Office Change Checklist
Filing instruction related to a Health Maintenance Organization's subsequent filing for a home office change
PDF English
FIN360
HMO Name Change Checklist
Instructions related to a Health Maintenance Organization's subsequent filing for a name change
PDF English
FIN361
HMO Service Area Expansion
Filing instructions for a Health Maintenance Organization wishing to provide HMO coverage in additional counties
PDF English
FIN363
HMO Merger Checklist
Checklist and instructions for a Health Maintenance Organization's merger filing
PDF English
FIN364
Cancellation of HMO Certificate of Authority
Instructions for a Health Maintenance Organization wishing to cancel its HMO certificate of authority to transact business in Texas
PDF English
FIN365
HMO Withdrawal Guidelines
Guidelines for a Health Maintenance Organization to file a plan of orderly withdrawal before the HMO undertakes total or substantial withdrawal.
PDF English
FIN367
Reciprocal or Inter-Insurance Exchanges (Form A-212)
Application to transact business as a reciprocal or inter-insurance exchange
PDF English
FIN368
Instructions for the Original Incorporation of Texas Lloyds Company
Instructions for the original incorporation of a Lloyds Company
PDF English
FIN369
Form A-211 (Lloyds)
Form for Lloyds companies to complete for a new or amended Certificate of Authority
PDF English
FIN370
Charter Amendment Guidelines for a Lloyds Plan
Instructions for Lloyds amendments, including Underwriter Substitution, Attorney-in-Fact Change, Name Change or Home Office Change, or Increase in Guaranty Fund or Surplus Contribution
PDF English
FIN371
Attorney-in-Fact Change Checklist for Reciprocals
Attorney-in-fact Change Checklist for Reciprocals (only)
PDF English
FIN372
Conversion of Lloyds to Stock P&C Insurer
Filing instructions for a Lloyds insurer to convert to a stock property and casualty insurer
PDF English
FIN373
Instructions for Certificate of Authority for Multiple Employer Welfare Arrangement
Filing instructions for preparing the application to become licensed as a Multiple Employer Welfare Arrangement (MEWA)
PDF English
FIN374
MEWA Application to Do Business
Application form to do business as a Multiple Employer Welfare Arrangement (MEWA)
PDF English
FIN375
Application for Initial Certificate of Authority (MEWA)
Multiple Employer Welfare Arrangement (MEWA) application for a temporary, or initial certificate of authority
PDF English
FIN376
MEWA Officers, Directors, and Trustees Page
Listing of all officers, directors, and trustees associated with the Multiple Employer Welfare Arrangement (MEWA)
PDF English
FIN377
Service of Process (MEWA)
Multiple Employer Welfare Arrangement (MEWA) Service of Process form
PDF English
FIN378
MEWA Annual Filing Checklist
Instructions for submitting annual filing for a Multiple Employer Welfare Arrangement (MEWA)
PDF English
FIN381
CCRC Filing Requirements for Certificate of Authority
Instructions for an entity wishing to operate as a Continuing Care Retirement Community (CCRC) in Texas
PDF English
FIN382
CCRC 1 - Application for Certificate of Authority to do Business in Texas
Continuing Care Retirement Community (CCRC) application for Certificate of Authority to do business in Texas, CCRC From #1
PDF English
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 Commissioner's approval to release loan reserve fund escrow amounts in excess of that allowed by rule (CCRC Form #2)
PDF English
FIN384
CCRC 3 - Officers and Directors Page
Continuing Care Retirement Community (CCRC) listing of all associated officers and directors, CCRC Form #3
PDF English
FIN385
CCRC 4 - Biographical Data Form for a For-Profit CCRC
Continuing Care Retirement Community (CCRC) biographical data form to be completed by any person serving as a board member for a for-profit CCRC, CCRC Form #4
PDF English
FIN386
CCRC 4A - CCRC Biographical Affidavit for a Not-For-Profit CCRC
Continuing Care Retirement Community (CCRC) biographical data form to be completed by any person serving as a board member for a Not-for-Profit CCRC, CCRC Form #4a
PDF English
FIN387
CCRC 5 - Acknowledgement of Delivery of Disclosure Statement
Continuing Care Retirement Community (CCRC) resident's acknowledgement of delivery of Disclosure Statement, CCRC Form #5
PDF English
FIN388
CCRC 6 - Format for Disclosure Statement
Continuing Care Retirement Community (CCRC) detailed instructions and format for submitting Disclosure Statement, CCRC Form #6
PDF English
FIN389
CCRC Form #6A - CCRC Instructions for Preparation of Disclosure Statement
Continuing Care Retirement Community (CCRC) instructions for preparing Disclosure Statement filing, CCRC Form #6a
PDF English
FIN390
CCRC 7 - Change of Control Statement
Continuing Care Retirement Community (CCRC) instructions including content and format in preparing statement regarding a change of control, CCRC Form #7
PDF English
FIN391
CCRC 8 - Certification of Changes to Disclosure Statement
Continuing Care Retirement Community (CCRC) certification of changes made to the Disclosure Statement, CCRC Form #8
PDF English
FIN392
CCRC 9 - Notice of Request to Release Entrance Fee Escrow Funds
Continuing Care Retirement Community (CCRC) written notice of request to release entrance fee escrow funds, CCRC Form #9
PDF English
FIN393
CCRC 10 - Notice of Request to Release Funds from the Reserve Fund Escrow Account
Continuing Care Retirement Community (CCRC) written notice of request to release funds from the reserve funds escrow account, CCRC Form #10
PDF English
FIN394
CCRC 11 - Notice by Provider of Re-Payment of Previously Released Funds to the Reserve Fund Escrow Account
Continuing Care Retirement Community (CCRC) Provider's affidavit for repayment of previously released funds to the Reserve Fund Escrow Account, CCRC Form #11
PDF English
FIN395
CCRC 12 - Escrow Agent's Affidavit of Re-payment of Previously Released Funds to the Reserve Fund Escrow Account
Continuing Care Retirement Community (CCRC) escrow agent's affidavit for repayment of previously released funds to the Reserve Fund Escrow Account, CCRC Form #12
PDF English
FIN396
CCRC 13 - Notice of Lien
Continuing Care Retirement Community (CCRC) written notice of lien, CCRC Form #13
PDF English
FIN397
CCRC 14 - Calculations Concerning Conditions
Continuing Care Retirement Community (CCRC) calculations concerning conditions, CCRC Form #14
PDF English
FIN398
CCRC Name Change Checklist
Continuing Care Retirement Community (CCRC) charter amendment checklist to effect a name change
PDF English
FIN403
Continuing Care Retirement Community (CCRC) Release of Funds from Escrow
Continuing Care Retirement Community (CCRC) instructions relating to written notice for a request of release of funds from the entrance fee escrow
PDF English
FIN404
Workers Compensation Group Self-Insurance Coverage Acknowledgement of Indemnity Agreement
Workers' Compensation Self-Insurance Group (SIG) coverage acknowledgement of indemnity agreement; employer's joint and several liability agreement
PDF English
FIN405
Company Licensing and Registration Open Records Request
Open Records Request form for the Company Licensing and Registration Office
PDF English
FIN406
Statutory Deposit Fee Transmittal Form
Fee transmittal form submitted with statutory deposit filings
PDF English
FIN407
Statutory Deposit Transaction Form
Statutory Deposit Transaction Form is submitted when a securities is deposited or withdrawn.
PDF English
FIN409
Texas PEO Quarterly Report
Quarterly report filed for PEO self-funded employee health benefit plans.
EXCEL English
FIN410
Texas PEO Annual Report
Annual financial report filed by PEO self-funded health benefit plans.
EXCEL English
FIN411
Financial Projections for Self-Funded PEO Plans
Financial projections to be submitted for a PEO self-funded health benefit plan.
EXCEL English
FIN412
Professional Employer Organization Application for a Certificate of Approval to Sponsor a Client Employer Health Benefit Plan
Certificate of approval application and checklist for a PEO sponsored Client Employer Health Benefit Plan
PDF English
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
PDF English
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
PDF English
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.
PDF English
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.
PDF English
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.
PDF English
FIN420
Risk Retention Group Initial and Annual Filing Requirements Checklist
Checklist provided to Risk Retention Groups to ensure all required documents are completed and submitted within required deadlines.
PDF English
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.
PDF English
FIN423
Alien non US domiciled Surplus Lines Insurers Filing Requirements Checklist
Instructions Checklist for alien non US 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. These requirements apply only to Alien Surplus
PDF English
FIN426
Form R-4, Accredited/Trusteed Reinsurer Checklist
See FIN425 for memo with further instructions. Accredited Reinsurers to submit this form with initial and annual filing.
PDF English
FIN427
Form R-1, Submission for Reinsurance Accreditation
See FIN425 for memo with further instructions.
PDF English
FIN428
Form R-3, Certificate of Assuming Insurer
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.
PDF English
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.
PDF English
FIN430
License Application for a Life Settlement Provider or Broker
Original application for licensure of a life settlement broker or provider, which includes checklists for filing requirements of the initial application
PDF English
FIN431
Application for Renewal, Surrender, or Change of Information for a Life Settlement Provider or Broker
Application for renewal of a broker or provider license or to report change of information of an existing life settlement broker or provider
PDF English
FIN432
Life Agent Notification to TDI to act as a Life Settlement Broker
Required for applicants who have held a resident Texas life or life and health license for at least one year
PDF English
FIN434
Biographical Affidavit for Life Settlement Providers or Brokers
Biographical affidavit. Must be completed by all individuals specified in the instructions of FIN430 and FIN431, as adopted by rule.
PDF English
FIN435
Initial Statutory Deposit Checklist
Checklist for an insurance company to initially place security funds on deposit
PDF English
FIN436
Name Change for Securities on Deposit Checklist
Checklist outlining documents required for an insurance company to change the name for which securities are held
PDF English
FIN437
Substituting Securities on Deposit Checklist
Checklist outlining documents required for an insurance company to substitute securities held on deposit
PDF English
FIN438
Withdrawal of Statutory Deposit Checklist
Instructions outlining documents required for an insurance company to withdraw securities on deposit, due to a reduction, dissolution, merger, or cancellation of company's Certificate of Authority
PDF English
FIN440
Instructions for Completing Securities Deposited Form 120
PDF English
FIN441
Securities Deposit Form 120 (FIN 441)
Securities Deposit Form 120, to be used by insurance companies. Refer to FIN440 for instructions in completing this form.
PDF English
FIN444
Instructions for Completing Securities Withdrawn Form 121
Instructions for completing securities withdrawn Form 121
PDF English
FIN445
Securities Withdrawn Form 121 (FIN445)
Securities Withdrawn Form 121, to be used by insurance companies. Refer to FIN444 for instructions in completing this form.
PDF English
FIN450
Joint Control Agreement
Form to be executed by Lloyds plan when placing required net assets as required by statute
PDF English
FIN451
Instructions for HMOs Placing Securities on Deposit
Instructions for Health Maintenance Organizations when placing securities on deposit
PDF English
FIN452
HMO Pledge Letter Example
Template for Health Maintenance Organizations to use when pledging assets, as required by statute
PDF English
FIN453
Declaration of Trust
Form to be executed for securities held on deposit
PDF English
FIN464
Bond of Administrator or Service Company for a Workers' Compensation Self-Insured Group
Format Instructions
PDF English
FIN465
Workers Compensation Self-Insurance Group Application
Application for Certificate of Approval to Conduct Workers Compensation Self-Insurance Group (SIG) Business
PDF English
FIN466
Workers Compensation Self-Insurance Group (SIG) Application Checklist
Application checklist for workers compensation Self-Insurance Groups (SIG)
PDF English
FIN467
Workers Compensation Self-Insurance Group (SIG) Employer Membership Form
Employer membership form for workers compensation Self-Insurance Groups
PDF English
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 (SIG) makes
PDF English
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
PDF English
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
PDF English
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
PDF English
FIN472
Workers Compensation Self-Insurance Group (SIG) Hazardous Financial Condition Notice
Instructions and checklist for a workers compensation Self-Insurance Group (SIG) should it become insolvent or discover a hazardous financial condition
PDF English
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
PDF English
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)
PDF English
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
PDF English
FIN476
Workers Compensation Self Insurance Group Changes to Corporate Governance Documents Checklist
Checklist for a workers compensation Self Insurance Group 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
PDF English
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
PDF English
FIN478
Workers Compensation Self-Insurance Group (SIG) Financial Pro Forma
Financial Pro Forma for a workers compensation Self-Insurance Group (SIG)
PDF English
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
PDF English
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
PDF English
FIN482
Notification that an Insurer or HMO will be acting as an Administrator
Form notifying TDI than an Insurer or HMO will be acting as an Administrator (TPA)
PDF English
FIN483
Transactions Cash Receipts Transmittal Form
PDF English
FIN483
Transactions Cash Receipts Transmittal Form
WORD English
FIN483
Transactions Cash Receipts Transmittal Form
PDF English
FIN483
Transactions Cash Receipts Transmittal Form
WORD English
FIN490
Certification of Financial Statement Form for Administrators
Form to be executed by authorized officer, attesting that the unaudited financial statement is a full and true statement of assets, etc.
PDF English
FIN491
Health Care Collaborative (HCC) Acquisition Form
Department notification of an acquisition of a Health Care Collaborative
PDF English
FIN492
Application for Certificate of Authority to do the business of a Health Care Collaborative in the state of Texas
Health Care Collaborative application for initial or renewal of certificate of authority
PDF English
FIN493
Health Care Collaboratives Officers and Directors Page
Health Care Collaborative Officer and Director Information
PDF English
FIN494
Health Care Collaborative Payor Information Form
Form used to provide HCC market power information
PDF English
FIN495
Request to Convert to Renewal of Certificate of Authority (to do the business of a Health Care Collaborative)
Used to request that the Department convert an examination to an early renewal application
PDF English
FIN496
Transmittal Checklist for Health Care Collaborative (HCC) Filings
Health Care Collaborative Filing Transmittal Checklist
PDF English
FIN501
Notice of Appointment or Appointment Termination
This form is used to report an insurer’s or agent’s appointment; or any termination of an appointment of an agent or subagent.
PDF English
FIN505
Licensing Corporate Insurance Agents Bond (aka Insurance Agency Bond)
Method of showing proof of financial responsibility to obtain corporate license.
PDF English
FIN506
Individual Application for Insurance License
Rev. 9/2017 - Used by individuals not required to pass a qualifying examination via Pearson VUE. Also used to apply for a Provisional Permit; for applicable license types.
PDF English
FIN507
Licensing Application for Insurance Agency License
Used by corporations, partnerships, depository institutions and other business entity eligible for an insurance agency license under the provisions of the Texas Insurance Code. Rev 2/2016
PDF English
FIN508
Annual Nonresident Public Insurance Adjuster Affidavit
Nonresident public insurance adjusters are required to certify, knowledge of certain laws. Rev. 12/2015
PDF English
FIN509
Public Insurance Adjuster Bond - Licensing
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.
PDF English
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 12/2015
PDF English
FIN511
Licensing Reinsurance Intermediary Biographical Affidavit
To register individuals to be associated to a Reinsurance Intermediary License. Rev 12/2015
PDF English
FIN512
Licensing Reinsurance Intermediary Agent For Service of Process
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.
PDF English
FIN513
Licensing Reinsurance Intermediary Bond
Method of showing proof of financial responsibility for a Reinsurance intermediary License.
PDF English
FIN514
Specialty Insurance License Application
FIN514 Specialty Insurance License Application (fka Li004,LHL207) Rev. 12/2015
PDF English
FIN515
Application for Provider Registration
Application to become a continuing education provider. Rev 02/2016 ( fka LHL212)
PDF English
FIN516
Application for Course Certification
Application for certification of Prelicensing or Continuing Education course. (fka LHL213) Rev. 10/2017
PDF English
FIN517
CE Exemption or Extension
Application for licensee CE Exemption or Extension. (fka LHL216) Rev. 2/2016
PDF English
FIN518
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. fka LHL240
PDF English
FIN519
CE Automatic Fines Transmittal
Continuing Education Fines (fka LHL257) Rev. 6/2015
PDF English
FIN520
Provider Renewal and Information Change Form
Application for Provider Renewal or Change of Contact Information. (fka LHL367)
PDF English
FIN521
Provider Audit Affidavit
Used only by continuing education providers (fka LHL386)
PDF English
FIN522
Licensee Request for Qualifying Credit
TEXAS Qualifying Continuing Education Credit (fka LHL615)
PDF English
FIN523
Request for Association Credit Accepted by TDI
Request for Association Credit (fka LHL617) Rev. 2/2015
PDF English
FIN524
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.
EXCEL English
FIN525
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.
PDF English
FIN526
Discount Health Care Program Operator Biographical Certificate Form
Discount Health Care Program Operator Biographical Certificates. Follow the instructions within the form for completion. Rev 12/2015
PDF English
FIN527
Discount Health Care Program Operator Registration Form
Form for Registration as a Discount Health Care Program Operator.
PDF English
FIN528
Registration of Assumed Name/Branch Locations/Entity Name Change
Commonly known as form LDTL, fka LHL203
PDF English
FIN529
ISR Transfer/Cancel Employment
ISR Transfer/Cancel Employment (fka LHL208)
PDF English
FIN530
Request for Letter(s) of Certification
Request for Letter(s) of Certification; Rev 01/2015
PDF English
FIN531
Biographical Form and Certification of License Qualification Following A Change of Control
Use this form to report changes to control of a licensed insurance agency; or to report new individuals to be associated with or disassociated from a currently licensed insurance agency.
PDF English
FIN532
Branch Office Address Change Request
Branch Office Address Change Request (fka LHL388)
PDF English
FIN533
Licensee Name/Address Change Request Form
Rev. 8/2017
PDF English
FIN535
Public Insurance Adjuster Contract
This contract form is prescribed by the Texas Department of Insurance to satisfy contract requirements for Public Insurance Adjusters effective January 01, 2014.
PDF English
FIN536
HEALTH MAINTENANCE ORGANIZATION PHYSICIAN/PROVIDER CONTRACT REQUIREMENTS
Used as guide to indicate the mandatory provisions and benefits required in a Provider Contract
PDF English
FIN537
WC Network Application Form
Workers' Compensation Health Care Network Application
PDF English
FIN542
HMO Delegation Agreement Checklist
PDF English
FIN543
Preferred Provider Benefit Plan and Exclusive Provider Benefit Plan Annual Report Form & Access Plan Checklist
PDF English
FIN544
HMO Network Access Plan Requirements
PDF English
FIN548
Captive Management Company Biographical Certificate Form
Form used for Captive Management Company's Biographical Certificate information. Follow the instructions within the form.
PDF English
FIN549
Captive Management Company Registration Form
Form used for Captive Management Company Registration information. Follow the instructions within the form.
PDF English
FIN550
WC Network Provider Contract Checklist
PDF English
FIN551
WC Network Insurance Carrier Contract Checklist
PDF English
FIN552
Workers' Compensation Network Access Plan Checklist
WC Network Access Plan Checklist
PDF English
FIN553
Workers' Compensation Health Care Network Management Contracts Checklist
PDF English
FIN573
Application for Navigator Individual Registration
Application form to register as an individual navigator, to be completed by individuals who do not currently have an active registration. Rev. 12/2015
PDF English
FIN574
Application for Navigator Entity Registration
Application to register as a navigator entity. Applicants must also submit TDI Form FIN576. Failure to submit both forms will result in an incomplete application; a registration will not be issued. Rev. 7/2015
PDF English
FIN575
Navigator Registration Surety Bond Form
Surety Bond Form to be submitted by a navigator entity who wishes to provide evidence of financial respsonsibility through a surety bond. Rev. 7/2015
PDF English
FIN576
Application for Navigator Entity Designated Responsible Party/Person
Includes biographical data on the DRP. The DRP applicant may also use this form to register as an individual navigator. The DRP does not need to complete a separate application for navigator individual registration. Rev. 12/2015
PDF English
FIN579
Renewal Application for Navigator Individual Registration
Rev. 9/2015 Renewal application to be completed by navigator individuals who have a current registration.
PDF English
FIN580
Renewal Application for Navigator Entity
Renewal application to be completed by navigator entities who have a current registration. Rev. 9/2015
PDF English
FIN581
Renewal Application for Navigator Entity Designated Responsible Party/Person
The DRP applicant may also use this form to register or re-register as an individual navigator. The DRP does not need to complete a separate application for navigator individual registration. Rev. 9/2015
PDF English
FIN582
CERTIFICATION OF INDEPENDENCE AND QUALIFICATIONS OF THE REVIEWER
PDF English
FIN583
Holder of Bonds or Notes Over $100,000
PDF English
FIN584
Form D Application Prior Notice of Transaction
PDF English
FIN585
Service Agreement Checklist
Management, Service, Cost Sharing, Tax Allocation, Rental, Lease Agreement Checklist
PDF English
FIN586
MGA Contract Review Checklist
Managing General Agency Contract Review Checklist
PDF English
FIN587
TPA Contract Review Checklist
Third Party Administrator Contract Review Checklist
PDF English
FIN588
Custodial Agreement Review Checklist
PDF English
FIN589
Addendum to Biographical Affidavit
PDF English
FIN590
Financial Analysis Fee Transmittal Form
for MEWAs and CCRCs
PDF English
FIN591
IRO Notice of Decision Template - HC
PDF English
FIN592
IRO Notice of Decision Template - WC
PDF English
fin593
HMO/INSURER PROMPT PAY PENALTY REPORTING FORM
PDF English
FIN594
Application for Residency Change to Texas
Eff. 9/1/2015; Rev 12/2015
PDF English
FIN596
Provider Network Contracting Entity Registration and Exemption Form
PNCE Registration and Exemption Form
PDF English
FIN599
Cybersecurity Checklist
PDF English
FIN601
HEALTH MAINTEANCE ORGANIZATION ANNUAL NETWORK ADEQUACY REPORT & ACCESS PLAN CHECKLIST
PDF English
Fingerprint Service Code Form
Texas Fingerprint Service Code Form
Used by applicants for fingerprinting process to identify Texas as the recipient of results and as authorization.
PDF English
FIN-NA
CE Example Course Evaluation
Sample Only
PDF English
FINT01
Escrow Officer Name/Address Change Request
Rev. 3/2016
PDF English
FINT02
Escrow Officer Renewal Application
Rev. 3/2016
PDF English
FINT02, FINT03, FINT04 Addendum
Renewal Application Addendum
Used for forms FINT02, FINT03, FINT04. Rev. 3/2016.
PDF English
FINT03
Title Agency Renewal Application
Rev. 3/2016
PDF English
FINT04
Direct Operation Renewal Application
Rev. 3/2016
PDF English
FINT05
CE Exemption/Extension Request
Rev. 3/2016
PDF English
FINT06
Title Continuing Education Course Application
Rev. 3/2016
PDF English
FINT07
Title Continuing Education Provider Application Packet
Rev. 3/2016
PDF English
FINT120
Abstract Plant Information
Title Agency Abstract Plant Information - Rev. 3/2016
PDF English
FINT122
Title Insurance Agent/Direct Operation Bond
Rev. 03/2016
PDF English
FINT123
Escrow Officers Schedule Bond
Rev. 3/2016
PDF English
FINT129
Title Agency Update Form
Used for Title Agency information updates Rev. 3/2016
PDF English
FINT130
Application For Direct Operation License
Rev. 3/2016
PDF English
FINT132
Application for Texas Escrow Officer's License
Rev. 03/2016
PDF English
FINT141
Agent Contract Submission Form
Rev. 3/2016
PDF English
FINT142
Notification for New Underwriter Appointments
Rev. 3/2016
PDF English
FINT143
Application for Texas Title Insurance Agent's License (Long Form)
Rev. 3/2016
PDF English
FR028
Suspected Insurance Fraud Report (SIU) Form
WORD English
FR028
Suspected Insurance Fraud Report (SIU) Form
PDF English
FR029
Suspected Insurance Fraud Reporting form for Consumers
PDF English
FR029
Suspected Insurance Fraud Reporting Form for Consumer
Consumer Fraud Report
WORD English
HMO001
Consumer Choice Evidence of Coverage (EOC) Checklist - Individual Plans
PDF English
HMO002
Consumer Choice Evidence of Coverage (EOC) Checklist - Large Employer and Conversion Plans
PDF English
HMO003
Consumer Choice Evidence of Coverage (EOC) Checklist - Small Employer and Conversion Plans
PDF English
HMO004
Evidence of Coverage (EOC) Checklist - Individual Plans
PDF English
HMO005
Evidence of Coverage (EOC) Checklist - Large Employer and Conversion Plans
PDF English
HMO006
Evidence of Coverage (EOC) Checklist - Small Employer and Conversion Plans
PDF English
HMO007
Evidence of Coverage (EOC) Checklist - Single Health Care Service Plan - Dental Care
PDF English
HMO008
Evidence of Coverage (EOC) Checklist - Single Health Care Service Plan - Vision Care
PDF English
PC428
Inspection Verification
Form WPI-2-BC-5 (for ongoing improvements whose construction began between January 1, 2008, and December 31, 2016)
PDF English
LAC001
Group Annuities Checklist
PDF English
LAC002
Individual Deferred Annuities Checklist
PDF English
LAC003
Single Premium Immediate Annuities Checklist
PDF English
LAC004
Variable Annuities Checklist
PDF English
LAC005
Group Life Insurance Checklist
PDF English
LAC006
Individual Term and Whole Life Checklist
PDF English
LAC007
Universal Life Insurance Checklist
PDF English
LAC008
Variable Life Insurance Checklist
PDF English
LAC009
Corporate Owned Life Insurance Checklist
PDF English
LAC010
Fraternal Filings Checklist
PDF English
LAC011
Nonprofit Legal Services Contracts Checklist
PDF English
LAC012
Private Placement Filings Checklist
PDF English
LAC013
Annuity and Life Applications Checklist
PDF English
LAC014
Life and Annuity Riders, Endorsements, and Amendments Checklist
PDF English
LAC015
Accelerated Death Benefits Checklist
PDF English
LAC016
Additional Insured's Checklist
PDF English
LAC017
Guaranteed Living Benefits Checklist
PDF English
LAC018
Index-Linked Crediting Features Checklist
PDF English
LAC019
Life Exclusions Checklist
PDF English
LAC020
Life Illustration Certification and Notification Checklist
PDF English
LAC021
Market Value Adjustments Checklist
PDF English
LAC022
Prepaid Funeral Filings Checklist
PDF English
LAC023
Return of Premium Checklist
PDF English
LAC024
Waiver of Premium Checklist
PDF English
LAC025
Individual and Group Credit Life and Credit Accident and Health Insurance Checklist
PDF English
LAC026
Life Settlement Forms Checklist
PDF English
LAH001
Credit Life and Credit Accident and Health Insurance Data Call
PDF English
LAH301
Noninsurance Benefits Checklist
PDF English
LAH302
Total and Partial Assumptions, Mergers, Name Changes, Redomestication, and Demutualization Form Filings Checklist
PDF English
LAH310
Transmittal Checklist for Life/Health Rate and Form Filings
PDF English
LAH311
Transmittal Checklist for Life/Health Miscellaneous Documents
PDF English
LAH312
Transmittal Checklist for HMO Rate and Form Filings
PDF English
LAH313
Transmittal Checklist for Advertising Filings
PDF English
LAH314
Advertising Annual Certification of Compliance
PDF English
LAH321
Credit Insurance Deviation Request Form
PDF English
LAH322
Actuarial Certification of Compliance for Indexed-Linked Annuities with an Additional Basis Point Reduction
PDF English
LAH323
Life Settlement Provider Data Report
PDF English
LAHR324
Notice and Consent for HIV-Related Testing
PDF English
LAHR330
Small Employer Carrier Status Certification
PDF English
LAHR331
Election and Application to be a Risk-Assuming or Reinsured Carrier
PDF English
LAHR332
Form Number 1212 CERT ANN LIST-OTHER/SEHBP
PDF English
LAHR334
Form Number 1212 CERT ACTUARIAL Annual Small Employer Health Benefit Plan Actuarial Certification
PDF English
LAHR335
Form Number 1212 CERT DATA Annual Small Employer Health Benefit Plan Report
PDF English
LAHR337
Large Employer Carrier Status Certification
PDF English
LAHR339
CCP Figure 1 - Required Disclosure Statement For All Consumer Choice Health Benefit Plans
PDF English
LAHR344
HMO Reconciliation of Benefits to Schedule of Charges
PDF English
LHL005
URA Application Form
Application to apply for URA Certification, renew a URA Certification or update a URA Certification
PDF English
LHL006
IRO Application
Application to apply for IRO Certification, renew an IRO Certification or update an IRO Certification
PDF English
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
PDF English
LHL009 Spanish
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
PDF Spanish
LHL050Rev0609
Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010
PDF English
LHL050Rev1204
Outline of Medicare Supplement Coverage
PDF English
LHL234
Application Package - Web Enterable
WORD English
LHL234
Application Package
PDF English
LHL234a
Other Professional Degrees - Web Enterable
A
WORD English
LHL234a
Other Professional Degrees
A
PDF English
LHL234a
Other Professional Degrees - Web Enterable
A
RTF English
LHL234
Application Package - Web Enterable
RTF English
LHL234b
Other Post-Graduate Education - Web Enterable
B
PDF English
LHL234b
Other Post-Graduate Education
B
PDF English
LHL234b
Other Post-Graduate Education - Web Enterable
B
RTF English
LHL234c
Other Work History - Web Enterable
C
WORD English
LHL234c
Other Work History
C
PDF English
LHL234c
Other Work History - Web Enterable
C
RTF English
LHL234d
Other Current Hospital Affiliations - Web Enterable
D
WORD English
LHL234d
Other Current Hospital Affiliations
D
PDF English
LHL234d
Other Current Hospital Affiliations - Web Enterable
D
RTF English
LHL234e
Other Previous Hospital Affiliations - Web Enterable
E
WORD English
LHL234e
Other Previous Hospital Affiliations
E
PDF English
LHL234e
Other Previous Hospital Affiliations - Web Enterable
E
RTF English
LHL234f
Other Practice Locations - Web Enterable
F
WORD English
LHL234f
Other Practice Locations
F
PDF English
LHL234f
Other Practice Locations - Web Enterable
F
RTF English
LHL234g
Malpractice Claims History - Web Enterable
G
WORD English
LHL234g
Malpractice Claims History
G
PDF English
LHL234g
Malpractice Claims History - Web Enterable
G
RTF English
LHL560
Long-Term Care Insurance Personal Worksheet
PDF English
LHL561
Long-Term Care Insurance Potential Rate Increase Disclosure Form
PDF English
LHL562
Long-Term Care Insurance Replacement and Lapse Reporting Form
PDF English
LHL563
Long-Term Care Insurance Recission Reporting Form
PDF English
LHL564
Long-Term Care Insurance Claim Denials Reporting Form
PDF English
LHL565
Long-Term Care Insurance Policies Sold Reporting Form
PDF English
LHL566
Long-Term Care Insurance Suitability Reporting Form
PDF English
LHL567
Things To Know Before You Buy Long-Term Care Insurance
PDF English
LHL568
Long-Term Care Insurance Suitability Letter
PDF English
LHL569
Partnership Status Disclosure Notice for Long-Term Care Partnership Policies/Certificates
PDF English
LHL570
Long-Term Care Partnership Program Insurer Certification Form
PDF English
LHL571
Long-Term Care Partnership Agent Training Certification Initial Reporting Form
PDF English
LHL572
Long-Term Care Partnership Agent Training Certification Form Annual Report
PDF English
LHL573
Insurer Certification of Association Compliance with Marketing Standards for Long-Term Care Partnership and Non-Partnership Policies and Certificates
PDF English
LHL610
Consumer Choice Health Benefit Plans Data Certification
PDF English
LHL658
Application for Approval of Exclusive Provider Benefit Plan (EPBP)
PDF English
MentorApp
Historically Underutilized Business
WORD English
New Employee Notice Vietnamese
New Employee Notice
covered and non-covered employers shall notify their employees of coverage status, in writing
PDF Vietnamese
New Employee Notice English
New Employee Notice
covered and non-covered employers shall notify their employees of coverage status, in writing
PDF English
New Employee Notice Spanish
New Employee Notice
Covered and non-covered employers shall notify their employees of coverage status in writing.
PDF Spanish
NOFR001
Prior Authorization of Health Care Services
PDF English
NOFR002
Prior Authorization of Prescription Drugs
PDF English
Notice 10 English
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF English
Notice 10 Spanish
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Spanish
Notice 10 Vietnamese
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Vietnamese
Notice 5 English
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF English
Notice 5 Spanish
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Spanish
Notice 5 Vietnamese
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Vietnamese
Notice 6 English
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF English
Notice 6 Spanish
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Spanish
Notice 6 Vietnamese
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Vietnamese
Notice 7 English
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF English
Notice 7 Spanish
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Spanish
Notice 7 Vietnamese
Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Vietnamese
Notice 8 English
Required Workers’ Compensation Coverage
(building or construction projects for governmental entities)
PDF English
Notice 8 Spanish
Required Workers’ Compensation Coverage
(building or construction projects for governmental entities)
PDF Spanish
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)
PDF English
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)
PDF Spanish
PC041
Texas Closed Claim Reporting Guide Order Form
Order form
PDF English
PC068
Roofing Installation Information and Certification for Reduction in Residential Insurance Premiums
Reduction in Residential Insurance Premiums
PDF English
PC144
Texas Commercial Liability Closed Claim Report (Long Form)
Long Form - Indemnity Payments of $75,000 or More
PDF English
PC145
Texas Commercial Liability Closed Claim Report (Short Form)
Short Form - Indemnity Payments Over $25,000 But Less Than $75,000
PDF English
PC321
Amusement Ride Certificate of Inspection/Reinspection
(Form AR-100)
PDF English
PC322
Texas Amusement Ride Safety Inspection and Insurance Act Daily Inspection Record
(Form AR-300)
PDF English
PC323
Amusement Ride Schedule of Operations in Texas
(Form AR-102)
PDF English
PC324
Quarterly Injury Report Amusement Ride Safety Inspection and Insurance Act
(Form AR-800)
PDF English
PC325
Quarterly Governmental Action Report Amusement Ride Safety Inspection and Insurance Act
(Form AR-801)
PDF English
PC326
Certificate of Mold Damage Remediation
Inspectors have to be licensed by the Texas Department of Health in order complete this form.
PDF English
PC327
Certificate of Appliance-Related Water Damage Remediation
PDF English
PC328
Use of Credit Information Disclosure
PDF English
PC328
El Declaración de Divulgación del Uso de Información de Crédito
PDF Spanish
PC340
Certification of Sections 2251.251 - 2251.252
Exemption Compliance (EC-1)
PDF English
PC350
Application for Windstorm Inspection Certificate of Compliance
Form WPI-1
PDF English
PC357
VIP Application for Residential Property Inspector License/Certificate
PDF English
PC358
P&C Filing Transmittal Form
PDF English
PC359
Texas Addendum
to NAIC Property & Casualty Transmittal Form
PDF English
PC360
Company Certification
Mortgage Guaranty Rate Filings
PDF English
PC361
Credit Scoring Model Filing Form
PDF English
PC362
Certification of Section 2251.1025
Exemption Compliance (EC-2)
PDF English
PC365
Exhibit C
Statewide Average Rate Level Information
PDF English
PC366
Exhibit D
Historical Experience
PDF English
PC367
Exhibit E
Expense Information - Including Disallowed Expense Adjustment
PDF English
PC368
Exhibit F
Expense Information - For Workers' Compensation and Mortgage Guaranty
PDF English
PC369
Exhibit G
Loss Costs Reference Information
PDF English
PC370
Exhibit H
Multi-Peril Rate Reference Information
PDF English
PC371
Exhibit L
Profit Provision Information
PDF English
PC372
Certificate of Insurability (VIP1)
PDF English
PC373
Residential Property Condition Evaluation Report (VIP2)
PDF English
PC374
Territory Exhibit
Display of Counties Affected by 15% Territory Rule
PDF English
PC375
CS Exhibit
Support for use of Credit Scoring
PDF English
PC376
Exhibit WC
Workers' Compensation
PDF English
PC377
Territory Exhibit
Support for Territorial Deviations
PDF English
PC381
Public Information Notice for Amusement Rides
PDF English
PC382
Inspection Verification Form
Form WPI-2-BC-6 (for ongoing improvements whose construction began on or after 1/1/2017)
PDF English
PC383
Loss Control Presentation Outline - Commercial Automobile/General Liability/Professional Liability for Insureds Other Than Hospitals
PDF English
PC384
Loss Control Presentation Outline - Medical Professional Liability
PDF English
PC385
Loss Control Presentation Outline - Professional Liability for Hospitals
PDF English
PC386
Commercial Automobile Liability Loss Control Information Worksheets
PDF English
PC387
General Liability Loss Control Information Worksheets
PDF English
PC388
Professional Liability and Medical Professional for Hospitals Loss Control Information Worksheets
PDF English
PC389
Qualification of Loss Control Representatives (LCRs) - Form 2
PDF English
PC390
Loss Control Representative Qualification Review
PDF English
PC391
Field Safety Representative with a Specialty in Hospitals Qualification Review
PDF English
PC392
Outline of a Minimum Plan for a Loss Control Program
PDF English
PC396
Insurer Registration Form For Access to Helpinsure.com
PDF English
PC400
Contact Information Update Request
(To be completed by Appointed Qualified Inspectors only)
PDF English
PC404
Compliance Questionnaire - Use of Credit Information
WORD English
PC404
Compliance Questionnaire - Use of Credit Information
PDF English
PC405
CM Exhibit
Additional Information for Certain County Mutuals
PDF English
PC406
Request for Application - Appraisal Umpires
PDF English
PC407
Request for Application - Mediators
PDF English
PC410
2014 TTIGA Guaranty Assessment Recoupment Charge Remittance Form
(Effective January 1 - December 31, 2014)
PDF English
PC411
Title Agent's Unencumbered Assets Certification (Form T-S1)
PDF English
PC412
Tripartite Agreement (Form T-S2)
PDF English
PC413
Solvency Account Release Request (Form T-S3)
PDF English
PC414
Annual Report of Title Company's Officers Authorized to Provide Information on Agent Financial Matters (Form T-S4)
PDF English
PC415
Financial Matter Disclosure Report (Form T-S4-A)
PDF English
PC416
Title Agent Certification of Agent's Quarterly Tax Reports (Form T-S5)
PDF English
PC417
Texas Title Insurance Agent's Minimum Capitalization Bond
PDF English
PC418
Prescribed Auto ID Card Form (28 TAC §5.204)
PDF English
PC419
Certificate of Insurance Filing Transmittal Form
PDF English
PC420
Exhibit A
Rate Filing Checklist
PDF English
PC421
Exhibit B
SERFF Rate Data
PDF English
PC422
County Exhibit
Average Premium Change by County
PDF English
PC423
VIP Renewal for Residential Property Inspector License/Certificate
PDF English
PC424
Form Usage Table
(Optional/Mandatory/Conditional Mandatory)
PDF English
PC425
Application for Appointment as a Qualified Inspector
Form AQI-1
PDF English
PC426
Renewal Application for Appointment as a Qualified Inspector
Form AQI-R
PDF English
PLN01
Notice of Denial of Compensability/Liability and Refusal to Pay Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN01
Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
Rev. 10/05
WORD English
PLN01S
Notice of Denial of Compensability/Liability and Refusal to Pay Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN01S
Notice of Denial of Compensability/Liability and Refusal to Pay (124.2(d))
Rev. 01/10
WORD Spanish
PLN02
Notice of First Temporary Income Benefit Payment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN02
Notification of First Temporary Income Benefit Payment (124.2(e)(1))
Rev. 10/05
WORD English
PLN02S
Notice of First Temporary Income Benefit Payment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN02S
Notification of First Temporary Income Benefit Payment (124.2(e)(1))
Rev. 01/10
WORD Spanish
PLN03
Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
Rev. 10/05
WORD English
PLN03A
Notice of Maximum Medical Improvement and No Permanent Impairment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN03AS
Notice of Maximum Medical Improvement and No Permanent Impairment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN03B
Notice of Maximum Medical Improvement and Permanent Impairment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN03BS
Notice of Maximum Medical Improvement and Permanent Impairment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN03C
Notice of Maximum Medical Improvement and Estimated Permanent Impairment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN03CS
Notice of Maximum Medical Improvement and Estimated Permanent Impairment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN03S
Notification of Maximum Medical Improvement/First Impairment Income Benefit Payment (124.2(e)(1)(4)&(5))
Rev. 08/10
WORD Spanish
PLN04
Notice Regarding Eligibility for Lifetime Income Benefits
Rev. 06/15, for use on or after June 1, 2015
WORD English
PLN04
Notice of Eligibility for Lifetime Income Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN04S
Notice of Eligibility for Lifetime Income Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN04S
Notice Regarding Eligibility for Lifetime Income Benefits
Rev. 06/15
WORD Spanish
PLN05
Notice of First Death Benefit Payment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN05
Notification of First Death Benefit Payment (124.2(e)(1))
Rev. 10/05
WORD English
PLN05S
Notice of First Death Benefit Payment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN05S
Notification of First Death Benefit Payment (124.2(e)(1))
Rev. 01/10
WORD Spanish
PLN06
Notice of Employer Full Salary Payment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN06
Notification of Employer Full Salary Payment (124.2(e)(7))
Rev. 10/05
WORD English
PLN06S
Notice of Employer Full Salary Payment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN06S
Notification of Employer Full Salary Payment (124.2(e)(7))
Rev. 08/10
WORD Spanish
PLN07
Notice of Change of Indemnity Benefit Type
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN07
Notification of Change of Indemnity Benefit Type (124.2(e)(4))
Rev. 10/05
WORD English
PLN07S
Notice of Change of Indemnity Benefit Type
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN07S
Notification of Change of Indemnity Benefit Type (124.2(e)(4))
Rev. 08/10
WORD Spanish
PLN08
Notice of Change in Amount of Indemnity Benefit Payment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN08
Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
Rev. 10/05
WORD English
PLN08S
Notice of Change in Amount of Indemnity Benefit Payment
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN08S
Notification of Change in Amount of Indemnity Benefit Payment (124.2(e)(2)&(3))
Rev. 08/10
WORD Spanish
PLN09
Notice of Suspension of Indemnity Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN09
Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
Rev. 10/05
WORD English
PLN09S
Notice of Suspension of Indemnity Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN09S
Notification of Suspension of Indemnity Benefit Payment (124.2(e)(6))
Rev. 08/10
WORD Spanish
PLN10
Notice of Reinstatement of Indemnity Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN10
Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
Rev. 10/05
WORD English
PLN10S
Notice of Reinstatement of Indemnity Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN10S
Notification of Reinstatement of Indemnity Benefit Payment (124.2(e)(5))
Rev. 08/10
WORD Spanish
PLN11
Notice of Disputed Issue(s) and Refusal to Pay Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN11S
Notice of Disputed Issue(s) and Refusal to Pay Benefits
Rev. 06/15
WORD Spanish
PLN11
Notice of Disputed Issue(s) and Refusal to Pay Benefits
Rev. 06/15
WORD English
PLN11S
Notice of Disputed Issue(s) and Refusal to Pay Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN12
Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD English
PLN12
Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 11/12
WORD English
PLN12S
Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 09/17 – Effective March 1, 2018. Insurance carriers may begin using the new notice now.
WORD Spanish
PLN12S
Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 11/12
WORD Spanish
SF008
Forensic Arson Lab - Physical Evidence Submission Form
Form for submitting evidence to the State Fire Marshal's arson laboratory.
PDF English
SF009
Evidence Can Quality Check Form
PDF English
SF025
Fire Extinguisher Certificate of Registration Application
New Companies and New Branch Offices
PDF English
SF026
Fire Extinguisher License Application
PDF English
SF027
Fire Extinguisher Apprentice Permit Application
PDF English
SF028
Fire Extinguisher Employee License Revision Application
PDF English
SF031
Fire Alarm Certificate of Registration Application
New Companies and New Branch Offices
PDF English
SF032
Fire Alarm License Application
PDF English
SF033
Revision/Transfer Application For All Types of Fire Alarm Licenses
PDF English
SF035
Fire Alarm Installation Certificate
PDF English
SF036
Fire Sprinkler Responsible Managing Employee (RME) License Application
PDF English
SF037
Fire Sprinkler Certificate of Registration Application
New Companies
PDF English
SF038
Revision/Transfer Application for Individuals
PDF English
SF039
Abbreviated Requirements for Fire Sprinkler Dwelling License and Registrations
PDF English
SF040
Sprinkler License & Test Information
PDF English
SF041
Contractor's Material and Test Certification for Aboveground Piping
PDF English
SF042
Contractor's Material and Test Certification for Underground Piping
PDF English
SF043
Application for Fireworks License and / or Permit
Distributors, Jobbers, Manufacturers, Wildlife, Agricultural and Industrial Permit
PDF English
SF044
Application for Class B Fireworks Singular or Multiple Display Permit
PDF English
SF045
Pyrotechnic, Special Effects and Flame Effects Operator's License Application
PDF English
SF047
Application for Retail Fireworks Permit
PDF English
SF084
Renewal Application - Fire Alarm Certificate of Registration
PDF English
SF086
Renewal Application - Fire Extinguisher Certificate of Registration
Renewal of companies and branch offices
PDF English
SF087
Renewal Application - Hydrostatic Testing Certificate of Registration
PDF English
SF088
Renewal Application - Fire Sprinkler Certificate of Registration
PDF English
SF091
Renewal Application - Fireworks License
Distributors, Jobbers, Manufacturers
PDF English
SF094
Renewal Application Fire Alarm Individual License
PDF English
SF099
Renewal Application - Fire Extinguisher License
Renewal of Individual Licenses
PDF English
SF100
Renewal Application - Fire Sprinkler Responsible Managing Employee
PDF English
SF104
Renewal Application - Fireworks Operator's License
PDF English
SF205
Fire Extinguisher System Installation Certification
PDF English
SF222
Retail Fireworks Indoor Site Information Form
PDF English
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).
PDF English
SF224
Licensing Investigation Complaint Form
A convenient form to use by anyone to report a suspected licensing violation to the SFMO.
PDF English
SF227
File Update Form
To update company address and authorized signatures
PDF English
SF228
Licensed Employee Termination Notice
PDF English
SF229
Guide to Obtain a Registration and License - Alarm
PDF English
SF234
Fire Extinguisher License and Test Information
PDF English
SF238
Fireworks License & Test Information
PDF English
SF239
Insurance Requirements
PDF English
SF242
Fire Drill Exit Report
2017-2018
PDF English
SF245
Abbreviated Guide to Obtain a Specialized License and Registration to Install Underground Fire Sprinkler Mains
PDF English
SF246
Training School Approval Application
Alarm Training Form
PDF English
SF247
Instructor Approval Application
Alarm Instructor Form
PDF English
SF250
Fire Standard Compliant Cigarette Manufacturer Form
Certification by Manufacturer
PDF English
SF251
Fire Standard Compliant Cigarette Manufacturer Form
Application for Fire Standard Compliant Cigarette Marking Approval
PDF English
SF252
Fire Standard Compliant Cigarettes Complaint Form
PDF English
SF254
Renewal Application Form for Fire Alarm Training Course Approval
PDF English
SF255
Renewal Application for Alarm Instructor Approval
PDF English
SF256
Texas Fire & Life Safety Educators
Website and Database Permission Form
PDF English
SF257
TXFLSE E-Group
PDF English
SF259
Fire Safety Inspection request form
PDF English
sf260
Forensic Arson Laboratory Evaluation Form
PDF English
sf260
Forensic Arson Laboratory Evaluation Form
PDF English
SN002
Notice to HMO Enrollees
PDF English
SN003
Workers Comp Network Sample Contingency Plan
PDF English
SN004
Workers Comp Net Sample Employee Acknowledgment Form
PDF English
SN005
Workers Comp Net Employee Acknowledgment Form
PDF Spanish
SN006
Workers Comp Net Sample Employee Acknowledgment Form - Chinese
PDF Chinese
SN007
Workers Comp Net Sample Employee Acknowledgment Form
PDF Vietnamese
SN008
Workers Comp Network Sample QI Report
PDF English
SN009
Sample URA Adverse Determination Notice, Health
PDF English
SN010
Sample URA Adverse Determination Notice, Specialty Health
PDF English
SN011
Sample URA Adverse Determination Notice, Workers Comp Net
PDF English
SN012
Sample URA Adverse Determination Notice, Workers Comp Non-Network
PDF English
SN013
Contract List
PDF English
SN014
Delegated Entity Data Form
Sample format for use by HMOs and WC HCNs when submitting delegation agreements to the Texas Department of Insurance
PDF English
sf261
Supplemental Criminal History Information
PDF English
TPA Annual Report Workbook
TPA Annual Report Workbook
Compilation of TPA Annual Report Forms FIN486-488, which can be submitted to meet TPA Annual Report requirements.
EXCEL English
Sample Notice
Notice of Underpayment of Income Benefits
Rev. 12/11
PDF English
Sample Notice
Aviso de Pago Insuficiente de los Beneficios de Ingresos
Rev. 12/11
PDF Spanish

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