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 | Filing Information |
|---|---|
| Agreements with Affiliates | File with Financial Analysis & Examinations, MC 303-1A |
| 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: |
| Cancellation of Certificate of Authority | Checklist: HMO Dissolution and Cancellation of Certificate of Authority (fin364hmodissv.pdf) |
| Cancellation/Fidelity Bonds of Management Company | File with Financial Analysis & Examinations, MC 303-1A |
| Capital Commitment Letters, Stock Subscription Agreements | File with Financial Analysis & Examinations, MC 303-1A |
| Certificate of Authority Admissions | Checklist: HMO CofA Application (fin357hmocaapp.pdf) Form: HMO Application for CofA (fin302hmocaapp.pdf) |
| Change in Administrative Offices | Checklist: HMO Home Office Change (fin359hmohochg.pdf) |
| Changes in Affiliate Chart | File with Financial Analysis & Examinations, MC 303-1A |
| Contracts with Officers & Directors | File with Financial Analysis & Examinations, MC 303-1A |
| DBA's, Trade, or Service Marks | Checklist: HMO D/B/A Filing (fin358hmodbaetc.pdf) Form: Name Application (fin300nameapp.pdf) |
| Dividends - Filings Not Required Currently | File with Financial Analysis & Examinations, MC 303-1A |
| Exclusive Agency Contracts | File with Financial Analysis & Examinations, MC 303-1A |
| Exemption from Change in Control of Affiliates |
File with Financial Analysis & Examinations, MC 303-1A |
| Fidelity Bonds of HMO | File with Financial Analysis & Examinations, MC 303-1A |
| Form A's | File with Financial Analysis & Examinations, MC 303-1A |
| HMO Biographical Update When changes occur, or send for licensure |
Form: Biographical Affidavit (fin311bioaff.pdf) |
| Management/Administrative Service/Marketing/Data Processing/Claims Agreement |
File with Financial Analysis & Examinations, MC 303-1A |
| Material Transaction Filings | File with Financial Analysis & Examinations, MC 303-1A |
| Mergers | Checklist: HMO Merger (fin363hmomerg.pdf) |
| Modification of Compensation Arrangements/Provider Contracts |
File with Financial Analysis & Examinations, MC 303-1A |
| Name Change | Checklist: HMO Name Change (fin360hmoncchg.pdf) Name Application (fin300nameapp.pdf) |
| Parental Guarantees | File with Financial Analysis & Examinations, MC 303-1A |
| Service Area Expansions | Checklist: HMO Service Area Expansion (fin361hmosae.pdf) Form: Biographical Affidavit (fin311bioaff.pdf) |
| Statutory Deposit | 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 | File with Financial Analysis & Examinations, MC 303-1A |
| Surplus Debenture Filings | File with Financial Analysis & Examinations, MC 303-1A |
| Total & Partial Assumption Agreements For questions regarding the Assumption Certificates Checklist, contact the Life Group at (512)322-3406. |
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: 04/12/2013
