Company Licensing and Registration Forms and Checklists
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| TDI form number | Description | Format | Language |
|---|---|---|---|
| CCRA01/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 |
English | |
| CCRC01a/FIN604 |
CCRC Form 1a - Application for authority to offer continuing care in residence in Texas under Health and Safety Code Section 246.0025(b). |
English | |
| CCRC02/FIN383 |
CCRC Form 2 - Application for Commissioner approval to release excess loan reserve escrow fund amounts under Health and Safety Code Section 278.078 |
English | |
| CCRC03/FIN384 |
CCRC Form 3 - Officers and directors page |
English | |
| CCRC04/FIN385 |
CCRC Form 4 - Biographical data form |
English | |
| CCRC04a/FIN386 |
CCRC Form 4A - Biographical data form for a not-for-profit CCRC board members |
English | |
| CCRC05/FIN387 |
CCRC Form 5 - Delivery of disclosure statement |
English | |
| CCRC06/FIN388 |
CCRC form 6 - Format for disclosure statement for continuing care facility |
WORD | English |
| CCRC06a/FIN389 |
CCRC Form 6A - Instructions for preparation a continuing care retirement community disclosure statement for filing with TDI |
English | |
| CCRC06b/FIN605 |
CCRC form 6B - Format for disclosure statement for continuing care facility |
WORD | English |
| CCRC07/FIN390 |
CCRC Form 7 - Change of control statement for CCRC |
English | |
| CCRC08/FIN391 |
CCRC Form 8 - Certification of changes to disclosure statement |
English | |
| CCRC09/FIN392 |
CCRC Form 9 - Notice of request to release entrance fee escrow funds |
English | |
| CCRC10/FIN393 |
CCRC Form 10 - Notice of request to release funds from the reserve fund escrow account |
English | |
| CCRC11/FIN394 |
CCRC Form 11 - Notice by provider of re-payment of previously released funds to the reserve fund escrow account |
English | |
| CCRC12/FIN395 |
CCRC Form 12 - Affidavit of re-payment of previously released funds to the reserve fund escrow account |
English | |
| CCRC13/FIN396 |
CCRC Form 13 - Notice of lien |
English | |
| CCRC14/FIN397 |
CCRC Form 14 - Calculations concerning conditions |
English | |
| CCRC14a/FIN607 |
CCRC Form 14a - Provider request for release of continuing care residence entrance fee escrow funds |
English | |
| CCRCFR/FIN381 |
CCRC Filing Requirements for Certificate of Authority |
English | |
| CCRCRE/FIN403 |
CCRC Release Escrow Checklist |
English | |
| CCRCNC/FIN398 |
CCRC Name Change Checklist |
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 |
English | |
| FIN181 |
Biographical Affidavit for Captive Insurance Company Biographical Affidavit form for individuals that oversee management of the Captive Insurance Company |
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 |
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 |
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 |
English | |
| FIN187 |
Uniform Checklist for Reciprocal Jurisdiction Reinsurers |
English | |
| FIN188 |
Application checklist for Certified Reinsurers |
English | |
| FIN189 |
Certificate of Accredited Assuming Insurer (AR-1) |
English | |
| FIN190 |
CR-1 Certificate of Certified Reinsurer |
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) |
English | |
| FIN197 |
Application Checklist for Accredited or Trusteed Assuming Insurer |
English | |
| FIN300 |
Company Name Application Application to reserve a company name |
English | |
| FIN302 |
HMO Application for Certificate of Authority Application for an HMO to do business in the state of Texas |
English | |
| FIN306 |
Officers and Directors Page Complete Listing of all Current Officers and Directors |
English | |
| FIN307 |
Attorney-in-Fact and Underwriters Page Lists the Attorney-in-Fact and Underwriters of Lloyds and Reciprocals |
English | |
| FIN310 |
Application For A License As An Advisory Organization Submit application to be licensed as an Advisory Organization |
English | |
| FIN311 |
Biographical Affidavit Biographical Affidavit form to be completed by certain officers and directors of insurance companies; compliance with statute |
English | |
| FIN312 |
Attorney for Service form Attorney for Service form |
English | |
| FIN321 |
Company Licensing Fee Transmittal Form |
English | |
| FIN324 |
Biographical Affidavit Update submitted as notification of changes to biographical affidavit |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
English | |
| FIN351 |
Voluntary Dissolution Checklist Instructions for a Texas-Domestic Company wanting to Dissolve and Cancel its Certificate of Authority |
English | |
| FIN353 |
Biographical Affidavit and Fingerprint Requirements for Texas-Domestic Insurers Requirements and instructions for submitting biographical affidavits and fingerprints for Texas-domestic insurers |
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) |
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 |
English | |
| FIN358 |
HMO DBA Filing Checklist Filing instructions relating to an HMO's DBA, Assumed Name, Trade Mark, Service Marks and Logos |
English | |
| FIN359 |
HMO Home Office Change Checklist Filing instruction related to a Health Maintenance Organization's subsequent filing for a home office change |
English | |
| FIN360 |
HMO Name Change Checklist Instructions related to a Health Maintenance Organization's subsequent filing for a name change |
English | |
| FIN361 |
HMO Service Area Expansion Filing instructions for a Health Maintenance Organization wishing to provide HMO coverage in additional counties |
English | |
| FIN363 |
HMO Merger Checklist Checklist and instructions for a Health Maintenance Organization's merger filing |
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. |
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. |
English | |
| FIN367 |
Application for Reciprocal or Inter-Insurance Exchanges Application to transact business as a reciprocal or inter-insurance exchange |
English | |
| FIN368 |
Instructions for the Original Incorporation of Texas Lloyds Company Instructions for the original incorporation of a Lloyds Company |
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 |
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 |
English | |
| FIN371 |
Checklist for Change in Attorney in Fact for Reciprocals Attorney-in-fact Change Checklist for Reciprocals (only) |
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 |
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) |
English | |
| FIN374 |
MEWA Application to Do Business Application form to do business as a Multiple Employer Welfare Arrangement (MEWA) |
English | |
| FIN375 |
Application for Initial Certificate of Authority (MEWA) Multiple Employer Welfare Arrangement (MEWA) application for a temporary, or initial certificate of authority |
English | |
| FIN376 |
MEWA Officers, Directors, and Trustees Page Listing of all officers, directors, and trustees associated with the Multiple Employer Welfare Arrangement (MEWA) |
English | |
| FIN377 |
Service of Process (MEWA) Multiple Employer Welfare Arrangement (MEWA) Service of Process form |
English | |
| FIN378 |
MEWA Annual Filing Checklist Instructions for submitting annual filing for a Multiple Employer Welfare Arrangement (MEWA) |
English | |
| FIN407 |
Statutory Deposit Transaction Form Statutory Deposit Transaction Form is submitted when a securities is deposited or withdrawn. |
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 |
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 |
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 |
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. |
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. |
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. |
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. |
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. |
English | |
| FIN435 |
Checklist for Placing an Initial Statutory Deposit Checklist for an insurance company to initially place security funds on deposit. |
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. |
English | |
| FIN437 |
Checklist for Substituting Securities on Deposit Checklist outlining documents required for an insurance company to substitute securities held on deposit. |
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. |
English | |
| FIN450 |
Joint Control Agreement for Lloyds Form to be executed by Lloyds plan when placing required net assets as required by statute |
English | |
| FIN453 |
Declaration of Trust Form to be executed for securities held on deposit. |
English | |
| FIN454 |
Checklist for Custodian Change for Securities on Deposit |
English | |
| FIN455 |
Checklist for Renewing a Certificate of Deposit |
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) |
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. |
English | |
| FIN590 |
Financial Analysis Fee Transmittal Form for MEWAs and CCRCs |
English |
For more information, contact: CompanyLicense@tdi.texas.gov