Listing of HMO Transactions Forms and Checklists
- Company Licensing & Registration Home Page
- Admitted Company Transactions
- Surplus Lines, Purchasing Group, Accredited/Trusteed Reinsurer and Risk Retention Group Transactions
- Viatical Registrations
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| HMO TRANSACTIONS |
DOWNLOAD FILE (Word/Excel) |
PDF FILE |
|---|---|---|
| Agreements with Affiliates | No checklist or form File with Financial Analysis & Examinations, MC 303-1A |
No checklist or form |
| Books and Records - Moving Out of Texas (TIC 804.102) File with Financial Analysis & Examinations |
Contact the Financial Analysis & Examinations division to request the Checklist and Form for moving books and records: FinancialAnalysis@tdi.state.tx.us | Contact the Financial Analysis & Examinations division to request the Checklist and Form for moving books and records: FinancialAnalysis@tdi.state.tx.us |
| Cancellation of Certificate of Authority | Checklist: HMO Dissolution and Cancellation of Certificate of Authority |
Checklist: HMO Dissolution and Cancellation of Certificate of Authority (fin364hmodissv.pdf) |
| Cancellation/Fidelity Bonds of Management Company |
No checklist or form File with Financial Analysis & Examinations, MC 303-1A |
No checklist or form |
| Capital Commitment Letters, Stock Subscription Agreements |
No checklist or form File with Financial Analysis & Examinations, MC 303-1A |
No checklist or form |
| Certificate of Authority Admissions |
Checklist: Checklist for HMO CofA Application Form: HMO Application for CofA |
Checklist: Checklist for HMO CofA Application (fin357hmocaapp.pdf) Form: HMO Application for CofA (fin302hmocaapp.pdf) |
| Change in Administrative Offices | Checklist: HMO Home Office Change |
Checklist: HMO Home Office Change (fin359hmohochg.pdf) |
| Changes in Affiliate Chart | No checklist or form File with Financial Analysis & Examinations, MC 303-1A |
No checklist or form |
| Contracts with Officers & Directors | No checklist or form File with Financial Analysis & Examinations, MC 303-1A |
No checklist or form |
| DBA's, Trade, or Service Marks |
|
Checklist: HMO D/B/A Filing (fin358hmodbaetc.pdf) Form: Name Application (fin300nameapp.pdf) |
| Dividends - Filings Not Required Currently |
No checklist or form File with Financial Analysis & Examinations, MC 303-1A |
No checklist or form |
| Exclusive Agency Contracts | No checklist or form File with Financial Analysis & Examinations, MC 303-1A |
No checklist or form |
| Exemption from Change in Control of Affiliates |
No checklist or form File with Financial Analysis & Examinations, MC 303-1A |
No checklist or form |
| Fidelity Bonds of HMO | No checklist or form File with Financial Analysis & Examinations, MC 303-1A |
No checklist or form |
| Form A's | No checklist or form File with Financial Analysis & Examinations, MC 303-1A |
No checklist or form |
| HMO Biographical Update When changes occur, or send for licensure |
Form: Biographical Affidavit (fin311bioaff.pdf) | |
| HMO Transmittal | Form: HMO Transmittal & Certification Form - Approval & Informational Filings (lhl259hmocklst.pdf) | |
| Management/Administrative Service/Marketing/Data Processing/Claims Agreement |
No checklist or form File with Financial Analysis & Examinations, MC 303-1A |
No checklist or form |
| Material Transaction Filings | No checklist or form File with Financial Analysis & Examinations, MC 303-1A |
No checklist or form |
| Mergers | Checklist: HMO Merger (fin363hmomerg.pdf) | |
| Modification of Compensation Arrangements/Provider Contracts |
No checklist or form File with Financial Analysis & Examinations, MC 303-1A |
No checklist or form |
| Name Change | Checklist: HMO Name Change (fin360hmoncchg.pdf) Name Application (fin300nameapp.pdf) | |
| Parental Guarantees | No checklist or form File with Financial Analysis & Examinations, MC 303-1A |
No checklist or form |
| Reduction of Deposit | Checklist: |
Checklist: |
| Service Area Expansions | Checklist: HMO Service Area Expansion (fin361hmosae.pdf) Form: Biographical Affidavit (fin311bioaff.pdf) | |
| Statutory Deposit | Pledge letter must be on bank letterhead |
Checklist: Instructions for Completing Form 120 (fin451hmoinstr.pdf) Instructions for Completing Form 121 (fin444instr121.pdf) Initial Statutory Deposit Checklist (fin435depositck.pdf) Name Change Checklist for Statutory Deposit (fin436namechgck.pdf) Substitution of Securities on Deposit Checklist (fin437substitut.pdf) Withdrawal of Statutory Deposit Checklist (fin438secwdraw.pdf) Texas Comptroller's Wiring Instructions (fin439wiring.pdf) Form: Form 120 Securities Deposited (fin441form120.pdf) Form 121 Securities Withdrawn (fin445form121.pdf) HMO Pledge Letter Example (fin452hmopledge.pdf) Pledge letter must be on bank letterhead |
| Stop Loss Reinsurance | No checklist or form File with Financial Analysis & Examinations, MC 303-1A |
No checklist or form |
| Surplus Debenture Filings | No checklist or form File with Financial Analysis & Examinations, MC 303-1A |
No checklist or form |
| Total & Partial Assumption Agreements For questions regarding the Assumption Certificates Checklist, contact the Life Group at (512)322-3406. |
Form: Affidavit of Lost Certificate of Authority (NAIC UCAA Form 15) |
Checklist: Total & Partial Reinsurance Agreements Involving a Domestic Company - Checklist (fin345domreins.pdf) Assumption Certificates Checklist - Life Div. (lhl356asckac.pdf) Form: Affidavit of Lost Certificate of Authority (NAIC UCAA Form 15) |
| Withdrawal | Checklist: HMO Withdrawal Guidelines (fin365hmowthdrw.pdf) |
For more information contact:
Last updated: 02/10/2012
