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 |
AH005
|
Group Health Discretionary Group Checklist
|
PDF |
English |
AH008
|
Group Health Employer Market Form Filing Checklist - Figure 40, 42, 47, 48, and 50
|
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 and Group Health Accident Only/ Accidental Death & Dismemberment Checklist
|
PDF |
English |
AH020
|
Individual and Group 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 |
AH025 (Fillable PDF)
|
Balance billing waiver
Fillable PDF version
|
PDF |
English |
AH025
|
Balance billing waiver
|
PDF |
English |
AS004
|
Accounting Texas Overhead Assessment
|
PDF |
English |
FIN382
|
CCRC Form 1 - Application for certificate of authority to do business in the State of Texas under Health and Safety Code Section 246.022
|
PDF |
English |
FIN604
|
CCRC Form 1a - Application for authority to offer continuing care in residence in Texas under Health and Safety Code Section 246.0025(b).
|
PDF |
English |
FIN383
|
CCRC Form 2 - Application for Commissioner approval to release excess loan reserve escrow fund amounts under Health and Safety Code Section 278.078
|
PDF |
English |
FIN384
|
CCRC Form 3 - Officers and directors page
|
PDF |
English |
FIN385
|
CCRC Form 4 - Biographical data form
|
PDF |
English |
FIN386
|
CCRC Form 4A - Biographical data form for a not-for-profit CCRC board members
|
PDF |
English |
FIN387
|
CCRC Form 5 - Delivery of disclosure statement
|
PDF |
English |
FIN388
|
CCRC form 6 - Format for disclosure statement for continuing care facility
|
WORD |
English |
FIN389
|
CCRC Form 6A - Instructions for preparation a continuing care retirement community disclosure statement for filing with TDI
|
PDF |
English |
FIN605
|
CCRC form 6B - Format for disclosure statement for continuing care facility
|
WORD |
English |
FIN390
|
CCRC Form 7 - Change of control statement for CCRC
|
PDF |
English |
FIN391
|
CCRC Form 8 - Certification of changes to disclosure statement
|
PDF |
English |
FIN392
|
CCRC Form 9 - Notice of request to release entrance fee escrow funds
|
PDF |
English |
FIN393
|
CCRC Form 10 - Notice of request to release funds from the reserve fund escrow account
|
PDF |
English |
FIN394
|
CCRC Form 11 - Notice by provider of re-payment of previously released funds to the reserve fund escrow account
|
PDF |
English |
FIN395
|
CCRC Form 12 - Affidavit of re-payment of previously released funds to the reserve fund escrow account
|
PDF |
English |
FIN396
|
CCRC Form 13 - Notice of lien
|
PDF |
English |
FIN397
|
CCRC Form 14 - Calculations concerning conditions
|
PDF |
English |
FIN607
|
CCRC Form 14a - Provider request for release of continuing care residence entrance fee escrow funds
|
PDF |
English |
CP029
|
Health Insurance Mediation Request Form
Request health insurance mediation
|
PDF |
English |
CP029-sp
|
Obtenga ayuda si recibió una factura sorpresa de un proveedor de servicios médicos
|
PDF |
Spanish |
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. 10/22
|
PDF |
English |
DWC003ME
|
Employee’s multiple employment wage statement
Rev. 05/23
|
PDF |
English |
DWC003MES
|
Declaración de salario de múltiples trabajos del empleado
Rev. 05/23
|
PDF |
Spanish |
DWC003S
|
Declaración de salarios del empleador
Rev. 10/22
|
PDF |
Spanish |
DWC003SD
|
Employer’s wage statement for school districts
Rev. 07/22
|
PDF |
English |
DWC003SDS
|
Declaración de salario del empleador para distritos escolares
Rev. 07/22
|
PDF |
Spanish |
DWC004
|
Employer's Contest of Compensability
Rev. 11/08
|
PDF |
English |
DWC005
|
Employer Notice of No Coverage or Termination of Coverage
Rev. 02/18 - For help and an instructional video see “Electronic Filing - Online Forms” page.
|
PDF |
English |
DWC005
|
Employer Notice of No Coverage or Termination of Coverage
Rev. 02/18 - static version for mailing and faxing
|
PDF |
English |
DWC005s
|
Aviso del Empleador de No Cobertura o de Cancelación de la Cobertura
Rev. 02/18
|
PDF |
Spanish |
DWC006
|
Supplemental Report of Injury
Rev. 10/05
|
PDF |
English |
DWC007
|
Employer’s report of noncovered employee’s work-related injury or illness
Rev. 02/22
|
PDF |
English |
DWC007S
|
Reporte del empleador para lesiones o enfermedades relacionadas con el trabajo de los empleados sin cobertura
Rev. 02/22
|
PDF |
Spanish |
DWC008
|
Return-to-Work Reimbursement Program for Employers
Rev. 04/10
|
PDF |
English |
DWC020A
|
Correction/Revision/Endorsement to Existing Policy
Rev. 10/05
|
PDF |
English |
DWC020SI
|
Self-Insured Governmental Entity Coverage Information
Rev. 08/12 - For help and an instructional video see “Electronic Filing - Online Forms” page.
|
PDF |
English |
DWC022
|
Request for a required medical examination (RME)
Rev. 06/23
|
PDF |
English |
DWC022S
|
Solicitud para un examen médico requerido
Rev. 06/23
|
PDF |
Chinese |
DWC024
|
Benefit Dispute Agreement
Rev. 11/17
|
PDF |
English |
DWC024s
|
Acuerdo para Disputa de Beneficios
Rev. 11/17
|
PDF |
Spanish |
DWC025
|
Benefit Dispute Settlement
Rev. 11/17
|
PDF |
English |
DWC025s
|
Acuerdo por Disputa de Beneficios
Rev. 11/17
|
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. 03/22
|
PDF |
English |
DWC029
|
Request for standard detailed data reports
Rev. 03/22
|
PDF |
English |
DWC031
|
Request to change payment period or purchase an annuity
Rev. 06/23
|
PDF |
English |
DWC031s
|
Solicitud para cambiar el periodo de pago o para la compra de una anualidad
Rev. 06/23
|
PDF |
Spanish |
DWC032
|
Request for designated doctor examination
Rev. 6/23
|
PDF |
English |
DWC032S
|
Solicitud para obtener un examen por parte de un médico designado
Rev. 06/23
|
PDF |
Spanish |
DWC033
|
Request to reduce income benefits due to contribution
Rev. 05/22
|
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. 12/23
|
PDF |
English |
DWC042S
|
Reclamación para obtener beneficios de compensación para trabajadores por causa de muerte
Rev. 12/23
|
PDF |
Spanish |
DWC044
|
Election to Engage in Arbitration
Rev. 06/12
|
PDF |
English |
DWC044S
|
Elección para Participar en un Arbitraje
Rev. 05/12
|
PDF |
Spanish |
DWC045
|
Request to schedule, reschedule, or cancel a benefit review conference (BRC)
Rev. 07/21
|
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, por su nombre y siglas en inglés)
Rev. 07/21
|
PDF |
Spanish |
DWC045M
|
Request to schedule, reschedule, or cancel a benefit review conference to appeal a medical fee dispute decision (BRC-MFD)
Rev. 07/21
|
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 (benefit review conference to appeal a medical fee dispute decision -BRC-MFD, por su nombre y
Rev. 07/21
|
PDF |
Spanish |
DWC046
|
Request to accelerate impairment income benefits
Rev. 08/22
|
PDF |
English |
DWC046S
|
Solicitud para acelerar los beneficios de ingresos de impedimento
Rev. 08/22
|
PDF |
Spanish |
DWC047
|
Request to advance benefits
Rev. 08/22
|
PDF |
English |
DWC047S
|
Solicitud para recibir beneficios por adelantado
Rev. 08/22
|
PDF |
Spanish |
DWC048
|
Request to get reimbursed for travel costs
Rev. 07/21
|
PDF |
English |
DWC048S
|
Solicitud para obtener un reembolso por gastos de viaje
Rev. 07/21
|
PDF |
Spanish |
DWC049
|
Request to Schedule a Medical Contested Case Hearing (MCCH)
Rev. 11/17
|
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. 11/17
|
PDF |
Spanish |
DWC051
|
Request for a lump sum payment of impairment income benefits (IIBs)
Rev. 06/23
|
PDF |
English |
DWC051S
|
Solicitud para recibir un pago en suma total de los beneficios de ingresos de impedimento
Rev. 06/23
|
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 to extend the date of maximum medical improvement for an approved spinal surgery
Rev. 06/23
|
PDF |
English |
DWC057S
|
Solicitud para extender la fecha del mejoramiento máximo médico para una cirugía aprobada de la columna vertebral
Rev. 06/23
|
PDF |
Spanish |
DWC058
|
Request for Interlocutory Order
Rev. 09/07
|
PDF |
English |
DWC060
|
Medical Fee Dispute Resolution Request
Rev. 02/21
|
PDF |
English |
DWC060S
|
Solicitud para Resolución de Disputas por Honorarios Médicos
Rev. 02/21
|
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 |
DWC066
|
Statement of Pharmacy Services
Rev. 12/11
|
PDF |
English |
DWC067
|
Designated doctor certification application
Rev. 4/23
|
PDF |
English |
DWC068
|
Designated doctor examination data report
Rev. 6/23
|
PDF |
English |
DWC069
|
Report of Medical Evaluation
Rev. 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. 09/19
|
PDF |
English |
DWC073s
|
Reporte de Estado de Trabajo
Rev. 09/19
|
PDF |
Spanish |
DWC074
|
Description of Injured Employee’s Employment
Rev. 9/09
|
PDF |
English |
DWC081
|
Agreement between general contractor and subcontractor to provide workers' compensation insurance
Rev. 10/21
|
PDF |
English |
DWC081S
|
Acuerdo entre el contratista general y el subcontratista para proporcionar un seguro de compensación para trabajadores
Rev. 10/21
|
PDF |
Spanish |
DWC082
|
Agreement between motor carrier and owner operator to provide workers' compensation insurance | Agreement to require owner operator to act as employer
Rev. 02/22
|
PDF |
English |
DWC082S
|
Acuerdo entre el transportista y el propietario operador para proporcionar un seguro de compensación para trabajadores Acuerdo para requerir que el propietario operador actúe como empleador
Rev. 02/22
|
PDF |
Spanish |
DWC083
|
Joint agreement to affirm independent relationship for certain building and construction workers | Agreement to establish employer-employee relationship for certain building and construction workers
Rev. 10/21
|
PDF |
English |
DWC083S
|
Acuerdo en conjunto para afirmar la relación independiente de ciertos trabajadores de edificación y construcción | Acuerdo para establecer la relación de empleador-empleado para ciertos trabajadores de edificación y construcción
Rev. 10/21
|
PDF |
Spanish |
DWC084
|
Exception to application of joint agreement to affirm independent relationship for certain building and construction workers
Rev. 10/21
|
PDF |
English |
DWC084S
|
Excepción a la aplicación del acuerdo en conjunto para afirmar la relación independiente de ciertos trabajadores de edificación y construcción
Rev. 10/21
|
PDF |
Spanish |
DWC085
|
Agreement between general contractor and subcontractor to establish independent relationship
Rev. 10/21
|
PDF |
English |
DWC085S
|
Acuerdo entre el contratista general y el subcontratista para establecer una relación independiente
Rev. 10/21
|
PDF |
Spanish |
DWC095
|
SIF Reimbursement Request Form - Overturned Order or Designated Doctor Opinion
Rev. 01/21
|
PDF |
English |
DWC096
|
SIF Reimbursement Request Form – Refund of Death Benefits
Rev. 01/21
|
PDF |
English |
DWC097
|
SIF Reimbursement Request Form – Multiple Employment
Rev. 01/21
|
PDF |
English |
DWC098
|
SIF Reimbursement Request Form – Pharmaceutical
Rev. 01/21
|
PDF |
English |
DWC101
|
Program review report for rejected risk employers
Rev. 11/21
|
PDF |
English |
DWC101
|
Program review report for rejected risk employers
Rev. 11/21
|
WORD |
English |
DWC102
|
Accident prevention plan cover sheet for rejected risk employer
Rev. 11/21
|
PDF |
English |
DWC102
|
Accident prevention plan cover sheet for rejected risk employer
Rev. 11/21
|
WORD |
English |
DWC104
|
Employer request for DWC safety consultation
Rev. 11/21
|
PDF |
English |
DWC104
|
Employer request for DWC safety consultation
Rev. 11/21
|
WORD |
English |
DWC105
|
Accident prevention services worksheet
Rev. 07/24
|
PDF |
English |
DWC105
|
Accident prevention services worksheet
Rev. 07/24
|
WORD |
English |
DWC105
|
Accident prevention services worksheet
Rev. 07/24
|
PDF |
English |
DWC105
|
Accident prevention services worksheet
Rev. 07/24
|
WORD |
English |
DWC109
|
Accident prevention services annual report
Rev. 07/24
|
PDF |
English |
DWC109
|
Accident prevention services annual report
Rev. 07/24
|
WORD |
English |
DWC109
|
Accident prevention services annual report
Rev. 07/24
|
PDF |
English |
DWC109
|
Accident prevention services annual report
Rev. 07/24
|
WORD |
English |
DWC120
|
Designation of administrative services company administrator
Rev. 03/22
|
PDF |
English |
DWC121
|
Claim Administration Contact Information
Rev. 3/20
|
PDF |
English |
DWC150
|
Notice of Representation
Rev. 12/16
|
PDF |
English |
DWC150A
|
Notice of Withdrawal of Representation
Rev. 11/17
|
PDF |
English |
DWC150AS
|
Aviso de Anulación de Representación Legal
Rev. 11/17
|
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. 11/17
|
PDF |
English |
DWC153
|
Request for Record Check or Copies of Confidential Claim Information
Rev. 02/21
|
PDF |
English |
DWC153s
|
Solicitud para Obtener Verificación de Expedientes o Copias de Información Confidencial de la Reclamación
Rev. 02/21
|
PDF |
Spanish |
DWC154
|
Workers' Compensation Complaint Form
Rev. 03/16
|
PDF |
English |
DWC154S
|
Quejas de Compensación para Trabajadores
Rev. 03/16
|
PDF |
Spanish |
DWC156
|
Prospective employment authorization and certification
Rev. 08/21
|
PDF |
English |
DWC156S
|
Certificación y autorización de un posible empleo
Rev. 08/21
|
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 |
EDI-02
|
Insurance carrier or trading partner medical electronic data interchange (EDI) profile
Rev. 04/22
|
PDF |
English |
EDI-03
|
Claim and medical EDI compliance coordinator and medical EDI trading partner notification
Rev. 02/22
|
PDF |
English |
FIN111
|
Health Entities Checklist
Filing requirements
|
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
Filing requirements
|
PDF |
English |
FIN122
|
Property & Casualty Insurers Filing Requirements Checklist
Filing requirements
|
PDF |
English |
FIN123
|
TDI Supplement Form for County Mutuals
|
PDF |
English |
FIN127
|
Title Checklist
Filing requirements
|
PDF |
English |
FIN128
|
Annual Statement Blank - Farm Mutual Companies
|
EXCEL |
English |
FIN128
|
Annual Statement Blank - Farm Mutual 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 FIN139 required to be filed annually by premium finance company, due April 1. Rev. 3/2021
|
PDF |
English |
FIN145
|
Notice of intent to relocate books and records outside of Texas
Form TDI BR-93
|
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 |
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 |
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 |
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 |
FIN187
|
Uniform Checklist for Reciprocal Jurisdiction Reinsurers
|
PDF |
English |
FIN188
|
Application checklist for Certified Reinsurers
|
PDF |
English |
FIN189
|
Certificate of Accredited Assuming Insurer (AR-1)
|
PDF |
English |
FIN190
|
CR-1 Certificate of Certified Reinsurer
|
PDF |
English |
FIN191
|
CR-F Certified Reinsurers
|
EXCEL |
English |
FIN192
|
CR-S Certified Reinsurers
CR-S, Certified Reinsurers, FIN192
|
EXCEL |
English |
FIN193
|
Certificate of Reinsurer Domiciled in Reciprocal Jurisdiction (RJ-1)
|
PDF |
English |
FIN194
|
Annuity Transaction Disclosure form
|
PDF |
English |
FIN195
|
Consumer Refusal to Provide Information Before Buying an Annuity form
|
PDF |
English |
FIN196
|
Consumer Disclosure When Buying an Annuity Not Recommended by an Agent
|
PDF |
English |
FIN197
|
Application Checklist for Accredited or Trusteed Assuming Insurer
|
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 |
FIN246
|
Affidavit for Exemption from Filing CPA Audited Financial Report
CPA Exemption Form
|
PDF |
English |
FIN251
|
Annual Statement Blank - Mutual Assessments, Burials, LMAs
|
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
|
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
|
Capital Changes Amendment for Texas Stock Property and Casualty or Life, Health and Accident Insurance Companies
Requirements for a capital increase requiring a charter amendment
|
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 |
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 |
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
|
Application for Reciprocal or Inter-Insurance Exchanges
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
|
Application for Certificate of Authority for a Texas Lloyds
Form for Lloyds companies to complete for a new or amended Certificate of Authority
|
PDF |
English |
FIN370
|
Checklist for Charter Amendment for Texas Lloyds
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
|
Checklist for Change in Attorney in Fact 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
|
PDF |
English |
FIN398
|
CCRC Name Change Checklist
|
PDF |
English |
FIN403
|
CCRC Release Escrow Checklist
|
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 |
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
|
Purchasing Group Annual Filing or Amendment - Form PG1R
Form PG1R - Form and instructions used by Purchasing Groups to report changes to the original registration and for annual filing due 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 |
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
|
Checklist for Placing an Initial Statutory Deposit
Checklist for an insurance company to initially place security funds on deposit.
|
PDF |
English |
FIN436
|
Checklist for a Name Change or Merger of Securities on Deposit
Checklist outlining documents required for an insurance company to change the name for which securities are held.
|
PDF |
English |
FIN437
|
Checklist for Substituting Securities on Deposit
Checklist outlining documents required for an insurance company to substitute securities held on deposit.
|
PDF |
English |
FIN438
|
Checklist for Withdrawal of Statutory Deposit
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 |
FIN450
|
Joint Control Agreement for Lloyds
Form to be executed by Lloyds plan when placing required net assets as required by statute
|
PDF |
English |
FIN453
|
Declaration of Trust
Form to be executed for securities held on deposit.
|
PDF |
English |
FIN454
|
Checklist for Custodian Change for Securities on Deposit
|
PDF |
English |
FIN455
|
Checklist for Renewing a Certificate of Deposit
|
PDF |
English |
FIN464
|
Workers' Compensation Self-Insured Group (SIG) Administrator or Service Company Bond
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 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 |
FIN484
|
Administrator Biographical Affidavit
TPA form to be completed by each principal (i.e. officer, director, partner, sole proprietor, or owner)
|
PDF |
English |
FIN485
|
Service of Process Form for Administrators
TPA form required from all foreign or alien applicants, appointing the commissioner of insurance as attorney for service of process.
|
PDF |
English |
FIN486
|
Annual Report Form for Administrators
TPA Form with required documents to be submitted annually by all Third-Party Administrators holding a certificate of authority under TIC Chapter 4151; due no later than June 30th, with $200 Annual Report filing fee.
|
PDF |
English |
FIN487
|
Annual Report for Insurers and HMOs Subject to 28 TAC 7.1605
TPA Form with required documents to be submitted annually by all Insurers and HMOs, subject to 28 TAC 7.1605; due no later than June 30th, with $200 Annual Report filing fee.
|
PDF |
English |
FIN488
|
Annual Report Exhibits A-E
Form to be submitted with annual report, summarizes business administered in Texas during preceding year
|
EXCEL |
English |
FIN489
|
Application for Certificate of Authority
Form and instructions for entities wishing to obtain a certificate of authority to do business as an Administrator (TPA) in Texas, under TIC Chapter 4151
|
PDF |
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 |
FIN497
|
Surrender of Third Party Administrator Certificate of Authority
Notice of surrendering the COA or Authority for a Third Party Administrator
|
PDF |
English |
FIN498
|
Third-Party Administrators Notice of Change of Address and/or Contact form
TPA to complete this form notifying the department of a change of address or other contact information
|
PDF |
English |
FIN499
|
Checklist for Administrator (TPA) Name Change
Checklist to be submitted by a Third-Party Administrator to effect a name change.
|
PDF |
English |
FIN501
|
Appointment Cancel for Cause
Use this form to submit notification of appointment cancellation for cause. All other appointment transactions must be completed electronically using National Insurance Producer Registry or Sircon.
|
PDF |
English |
FIN502
|
Notice of Change of Control
Third-Party Administrator's authorized officer to complete this form for a change of control
|
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 |
FIN507
|
Application for insurance agency license
Use for county mutual, risk manager, funeral pre-arrangement life, life and health insurance counselor, and life insurance not exceeding $25,000. For other license types, apply online at www.Sircon.com.
|
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 Section 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.
|
PDF |
English |
FIN511
|
Licensing Reinsurance Intermediary Biographical Affidavit
To register individuals to be associated to a Reinsurance Intermediary License.
|
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
Specialty Insurance License Application (fka Li004,LHL207)
|
PDF |
English |
FIN517
|
CE Exemption or Extension
Application for licensee CE Exemption or Extension. Revised 07/2020
|
PDF |
English |
FIN519
|
CE Automatic Fines Transmittal
Continuing Education Fines. Revised 07/2020
|
PDF |
English |
FIN520
|
CE provider information update
|
PDF |
English |
FIN521
|
Provider Audit Affidavit
Used only by continuing education providers. Revised 01/2019
|
PDF |
English |
FIN522
|
Licensee Request for Qualifying Credit
TEXAS Qualifying Continuing Education Credit (fka LHL615). Revised 07/2020
|
PDF |
English |
FIN523
|
Request for Association Credit Accepted by TDI
Request for Association Credit (fka LHL617). Revised 01/2019
|
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. Rev. 01/2019
|
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 01/2019
|
PDF |
English |
FIN527
|
Discount Health Care Program Operator Registration Form
Form for Registration as a Discount Health Care Program Operator. Rev. 01/2019
|
PDF |
English |
FIN528
|
Entity Name Change/ Assumed Name (DBA) Request
Use this form to update an official entity name change or register an assumed name (DBA) with TDI.
|
PDF |
English |
FIN529
|
Life Agent License Use Affidavit
Request CE waiver for life insurance not exceeding $25,000 agent licenses.
|
PDF |
English |
FIN530
|
Voluntary Surrender of Texas Insurance License
|
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 |
FIN533
|
Agent / Adjuster name or address change request form
|
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 |
FIN540
|
Agency address change request form
|
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 |
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 |
FIN590
|
Financial Analysis Fee Transmittal Form
for MEWAs and CCRCs
|
PDF |
English |
FIN594
|
Application for Residency Change to Texas
|
PDF |
English |
FIN599
|
Cybersecurity Checklist
|
PDF |
English |
FIN609
|
Annual Verification of Fidelity Bond Coverage (HMO Employee)
|
PDF |
English |
FIN610
|
Annual Verification of Fidelity Bond Coverage (management contractor employees)
|
PDF |
English |
FIN611
|
RFQ Application – Claims Services
|
PDF |
English |
FIN612
|
RFQ Application – Information Technology Services
|
PDF |
English |
FIN613
|
RFQ Application – Legal Services
|
PDF |
English |
FIN614
|
RFQ Application – Reinsurance Services
|
PDF |
English |
FIN615
|
RFQ Application – Special Deputy Receiver
|
PDF |
English |
FIN616
|
RFQ Application – Accounting Services
|
PDF |
English |
FIN700
|
Appointment certification
|
PDF |
English |
FIN-NA
|
CE Example Course Evaluation
Sample Only
|
PDF |
English |
FINT01
|
Escrow Officer Name/Address Change Request
|
PDF |
English |
FINT03
|
Title insurance agent or direct operation renewal application
Renew online at Sircon and follow the TDI tutorials before starting the renewal process.
|
PDF |
English |
FINT05
|
CE Exemption/Extension Request
|
PDF |
English |
FINT08
|
Title insurance licensing biographical information
|
PDF |
English |
FINT09
|
Escrow officer appointment
|
PDF |
English |
FINT10
|
Title insurance agent or direct operation appointment
|
PDF |
English |
FINT22
|
Title licensee: continuing education credit request
|
PDF |
English |
FINT120
|
Abstract Plant Information
Title Agency Abstract Plant Information
|
PDF |
English |
FINT122
|
Title Insurance Agent/Direct Operation Bond
|
PDF |
English |
FINT123
|
Escrow Officers Schedule Bond
|
PDF |
English |
FINT129
|
Title insurance agent or direct operation change request form
Used for Title Agency information updates
|
PDF |
English |
FINT143
|
Application for title insurance agent or direct operation license
Apply online at www.Sircon.com and follow tutorials provided on TDI website for fastest processing.
|
PDF |
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 Consumers (Spanish)
|
PDF |
Spanish |
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 |
HR197
|
Acknowledgement of Mandatory Training
|
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 |
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 |
LAH301
|
Noninsurance Benefits Checklist
|
PDF |
English |
LAH302
|
Total and Partial Assumptions, Mergers, Name Changes, Redomestication, and Demutualization Form Filings Checklist
|
PDF |
English |
LAH303
|
Advertising Product Review Checklist
|
PDF |
English |
LAH310
|
Life and Health Transmittal Form
|
PDF |
English |
LAH311
|
Life, Health and HMO Miscellaneous Documents Transmittal Checklist
|
PDF |
English |
LAH312
|
HMO Transmittal Checklist and Certification Form
|
PDF |
English |
LAH313
|
Advertising Transmittal Checklist and Certification Form
|
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 |
LAH345
|
Mandated Benefits and Mandated Offers Reporting Form
|
PDF |
English |
LAHR324
|
Notice and Consent for HIV-Related Testing
|
PDF |
English |
LAHR330
|
Small Employer Carrier Status Certification
|
PDF |
English |
LAHR334
|
Form Number 1212 Cert Actuarial Annual Small Employer Health Benefit Plan Actuarial Certification - Figure 47
|
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 |
LAHR339 - Example 1
|
Employer example of LAHR339 (Form CCP1)
|
WORD |
English |
LAHR339 - Example 2
|
Healthcare.gov example of LAHR339 (Form CCP1)
|
WORD |
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 |
LHL007
|
Supplemental Certification for IRO Renewal
Attach this form to the renewal application. You can attach it in the online renewal form or with the IRO Application, Form LHL006.
|
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
|
Solicitud para una revisión por parte de una Organización de Revisión Independiente
[En Español] - Solicitud para pedir una revisión por parte de una Organización de Revisión Independiente (Independent Review Organization- IRO por su nombre y siglas en inglés) para las disputas médicas necesarias de pacientes, empleados lesionados, representantes del paciente o proveedores de atención médica.
|
PDF |
Spanish |
LHL011
|
Notice of Rescission of Preauthorization Exemption and Right to Request an Independent Review
|
PDF |
English |
LHL050
|
Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or after June 1, 2010
|
PDF |
English |
LHL050
|
Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010
This form must be used beginning July 1, 2019.
|
PDF |
English |
LHL234
|
Application Package
|
PDF |
English |
LHL234a
|
Other Professional Degrees
Attachment A
|
PDF |
English |
LHL234b
|
Other Post-Graduate Education
Attachment B
|
PDF |
English |
LHL234c
|
Other Work History
Attachment C
|
PDF |
English |
LHL234d
|
Other Current Hospital Affiliations
Attachment D
|
PDF |
English |
LHL234e
|
Other Previous Hospital Affiliations
Attachment E
|
PDF |
English |
LHL234f
|
Other Practice Locations
Attachment F
|
PDF |
English |
LHL234g
|
Malpractice Claims History
Attachment G
|
PDF |
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 |
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 Exclusive Provider Benefit Plan (EPO) and Preferred Provider Benefit Plan (PPO)
|
PDF |
English |
LHL705
|
Workers’ Compensation Health Care Network Application
|
PDF |
English |
LHL707
|
HMO Network Access Plan Requirements
|
PDF |
English |
LHL708
|
Workers' Compensation Network Access Plan Checklist
WC Network Access Plan Checklist
|
PDF |
English |
LHL709
|
Certification of Independence and Qualifications of the Reviewer
|
PDF |
English |
LHL710
|
Holder of Bonds or Notes Over $100,000
|
PDF |
English |
LHL711
|
Addendum to Biographical Affidavit
|
PDF |
English |
LHL712
|
IRO Notice of Decision Template - HC
|
WORD |
English |
LHL713
|
IRO Notice of Decision Template - WC
|
WORD |
English |
LHL714
|
IRO Notice of Decision Template - Rescission
|
WORD |
English |
LHL715
|
Provider Network Contracting Entity Registration and Exemption of Affiliates Form
PNCE Registration and Exemption Form
|
PDF |
English |
LHL716
|
Health Maintenance Organization Annual Network Adequacy Report and Access Plan Checklist
|
PDF |
English |
LHL717
|
Utilization Review Agent's (URA) Designated Contact for IRO Requests
|
PDF |
English |
LHL718
|
Health Maintenance Organization (HMO) Physician / Provider Contract Requirements
Used as guide to indicate the mandatory provisions and benefits required in a Provider Contract
|
PDF |
English |
LHL719
|
HMO Delegation Agreement Checklist
|
PDF |
English |
LHL720
|
Workers' Compensation Health Care Network Provider Contract Checklist
|
PDF |
English |
LHL721
|
Workers’ Compensation Network Contract with Insurance Carrier Contract Requirements Checklist
|
PDF |
English |
LHL722
|
Workers' Compensation Health Care Network Management Contract Checklist
|
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
|
Texas Standard Prior Authorization Request Form for Prescription Drug Benefits
|
PDF |
English |
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 |
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 |
PC068
|
Impact-Resistant Roofing Installation Form
Roofing Installation Information and Certification for Reduction in Residential Insurance Premiums.
|
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 License and Regulation in order complete this form.
|
PDF |
English |
PC327
|
Certificate of Appliance-Related Water Damage Remediation
|
PDF |
English |
PC328 (CD-1)
|
Use of Credit Information Disclosure
|
PDF |
English |
PC328 (CD-1)
|
Divulgación del Uso de la Información de Crédito
|
PDF |
Spanish |
PC340
|
Certification of Sections 2251.251 - 2251.252
Exemption Compliance (EC-1)
|
PDF |
English |
PC350 (WPI-1)
|
Application for Windstorm Inspection Certificate of Compliance
|
PDF |
English |
PC357
|
VIP Application for Residential Property Inspector License/Certificate
|
PDF |
English |
PC358
|
P&C Filing Transmittal Form
|
PDF |
English |
PC360
|
Company Certification
Mortgage Guaranty Rate Filings
|
PDF |
English |
PC361
|
Credit Scoring Model Filing Form
|
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 (WPI-2-BC-6)
|
Inspection Verification
For projects that began construction between January 1, 2017, and August 31, 2020
|
PDF |
English |
PC390
|
Loss Control Representative Qualification Review
|
PDF |
English |
PC391
|
Field Safety Representative with a Specialty in Hospitals Qualification Review
|
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
|
Appraisal Umpire Roster Application
|
PDF |
English |
PC407
|
Mediator Roster Application
|
PDF |
English |
PC410
|
2018 TTIGA Guaranty Assessment Recoupment Charge Remittance Form
(Effective January 1 - December 31, 2018)
|
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 — short version (up to 90 forms)
Optional/Mandatory/Conditional Mandatory
|
PDF |
English |
PC425 (AQI-1)
|
Application for Appointment as a Qualified Inspector
|
PDF |
English |
PC426 (AQI-R)
|
Application Renewal for Appointment as a Qualified Inspector
|
PDF |
English |
PC427
|
Form usage table — long version (up to 470 forms)
Optional/Mandatory/Conditional Mandatory
|
PDF |
English |
PC428 (WPI-2-BC-5)
|
Inspection Verification
For ongoing improvements for construction that began between January 1, 2008, and December 31, 2016.
|
PDF |
English |
PC434 (WPI-2E)
|
Application for Certificate of Compliance
For completed improvements.
|
PDF |
English |
PC436 (WPI-2-BC-7)
|
Inspection Verification
For ongoing improvements for construction that began on or after April 1, 2020 (2018 building code).
|
PDF |
English |
PLN01
|
Notice of Denial of Compensability/Liability and Refusal to Pay Benefits
Rev. 07/21
|
WORD |
English |
PLN01S
|
Notice of Denial of Compensability/Liability and Refusal to Pay Benefits
Rev. 07/21
|
WORD |
Spanish |
PLN02A
|
Notice of First Temporary Income Benefit Payment
Rev. 07/21
|
WORD |
English |
PLN02AS
|
Notice of First Temporary Income Benefit Payment
Rev. 07/21
|
WORD |
Spanish |
PLN02B
|
Notice of first payment of income benefits on an acquired claim
Rev. 07/23
|
WORD |
English |
PLN02BS
|
Notice of first payment of income benefits on an acquired claim
Rev. 07/23
|
WORD |
Spanish |
PLN03A
|
Notice of Maximum Medical Improvement and No Permanent Impairment
Rev. 07/21
|
WORD |
English |
PLN03AS
|
Notice of Maximum Medical Improvement and No Permanent Impairment
Rev. 07/21
|
WORD |
Spanish |
PLN03B
|
Notice of Maximum Medical Improvement and Permanent Impairment
Rev. 07/21
|
WORD |
English |
PLN03BS
|
Notice of Maximum Medical Improvement and Permanent Impairment
Rev. 07/21
|
WORD |
Spanish |
PLN03C
|
Notice of Maximum Medical Improvement and Estimated Permanent Impairment
Rev. 07/21
|
WORD |
English |
PLN03CS
|
Notice of Maximum Medical Improvement and Estimated Permanent Impairment
Rev. 07/21
|
WORD |
Spanish |
PLN04
|
Notice of Eligibility for Lifetime Income Benefits
Rev. 07/21
|
WORD |
English |
PLN04S
|
Notice of Eligibility for Lifetime Income Benefits
Rev. 07/21
|
WORD |
Spanish |
PLN05
|
Notice of First Death Benefit Payment
Rev. 07/21
|
WORD |
English |
PLN05S
|
Notice of First Death Benefit Payment
Rev. 07/21
|
WORD |
Spanish |
PLN06
|
Notice of Employer Full Salary Payment
Rev. 07/21
|
WORD |
English |
PLN06S
|
Notice of Employer Full Salary Payment
Rev. 07/21
|
WORD |
Spanish |
PLN07
|
Notice of Change of Indemnity Benefit Type
Rev. 07/21
|
WORD |
English |
PLN07S
|
Notice of Change of Indemnity Benefit Type
Rev. 07/21
|
WORD |
Spanish |
PLN08
|
Notice of Change in Amount of Indemnity Benefit Payment
Rev. 07/23
|
WORD |
English |
PLN08S
|
Notice of Change in Amount of Indemnity Benefit Payment
Rev. 07/23
|
WORD |
Spanish |
PLN09
|
Notice of Suspension of Indemnity Benefits
Rev. 07/21
|
WORD |
English |
PLN09S
|
Notice of Suspension of Indemnity Benefits
Rev. 07/21
|
WORD |
Spanish |
PLN10A
|
Notice of reinstatement of indemnity benefits
Rev. 07/23
|
WORD |
English |
PLN10AS
|
Notice of reinstatement of indemnity benefits
Rev. 07/23
|
WORD |
Spanish |
PLN10B
|
Notice of lump sum payment of income or death benefits
Rev. 07/23
|
WORD |
English |
PLN10BS
|
Notice of lump sum payment of income or death benefits
Rev. 07/23
|
WORD |
Spanish |
PLN11
|
Notice of Disputed Issues and Refusal to Pay Benefits
Rev. 07/23
|
WORD |
English |
PLN11S
|
Notice of Disputed Issues and Refusal to Pay Benefits
Rev. 07/23
|
WORD |
Spanish |
PLN12
|
Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 12/23
|
WORD |
English |
PLN12S
|
Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 12/23
|
WORD |
Spanish |
PLN14
|
Notice of Continuing Investigation
Rev. 07/23
|
WORD |
English |
PLN14S
|
Notificación de Investigación en Curso
Rev. 07/23
|
WORD |
Spanish |
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
|
Application to Revise or Transfer All Types of Fire Extinguisher Licenses
|
PDF |
English |
SF031
|
Fire Alarm Certificate of Registration Application
New Companies and New Branch Offices
|
PDF |
English |
SF032
|
Individual Application for All Types of Fire Alarm Licenses
|
PDF |
English |
SF033
|
Application to Revise or Transfer 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 |
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 |
SF054
|
Branch Office Update Form
|
PDF |
English |
SF084
|
Fire Alarm Certificate of Registration Renewal Application
|
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
|
Individual License Renewal Application for All Types of Fire Alarm Licenses
|
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 |
SF146
|
Texas Fire Department Identification (FDID) Number Request Application
|
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 |
SF227
|
Company Information Update Form
To update company address and authorized signatures
|
PDF |
English |
SF228
|
Licensed Employee Termination Notice
|
PDF |
English |
SF230
|
Fireworks Company Information Update Form
|
PDF |
English |
SF246
|
Fire Alarm Training School Approval Application
Alarm Training Form
|
PDF |
English |
SF247
|
Fire Alarm 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 |
SF254
|
Fire Alarm Training School Renewal Application
|
PDF |
English |
SF255
|
Fire Alarm Instructor Renewal Application
|
PDF |
English |
SF259
|
Fire Safety Inspection Request Form
|
PDF |
English |
SF261
|
Supplemental Criminal History Information
|
PDF |
English |
SF265
|
Application Fee Exemption Form - Armed Services
|
PDF |
English |
SF266
|
Fire Suppression Rating Oversight Complaint Form
|
PDF |
English |
SF272
|
Application to Revise All Types of Individual Fireworks Licenses
|
PDF |
English |
SF300
|
Course Location and Schedule
|
PDF |
English |
SF400
|
Extinguisher Fixed Support System
|
PDF |
English |
SF500
|
Applicant's Employer Information
|
PDF |
English |
SF525
|
Fire Sprinkler Non-Resident Responsible Managing Employee (RME-G) Application Questions
|
PDF |
English |
SF550
|
Fire Sprinkler Non-Resident Responsible Managing Employee-Underground Fire Main (RME-U) Application Questions
|
PDF |
English |
SF600
|
Fireworks Online Application Supplement
|
PDF |
English |
SN002
|
Notice to HMO Enrollees: Have a complaint about your HMO?
|
PDF |
English |
SN002s
|
¿Tiene una queja relacionada con su HMO?
|
PDF |
Spanish |
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 |
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 |