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HMO Transactions Forms and Checklists - Company Licensing and Registration

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For more information regarding any of the topics below, go to the Company Licensing and Registration home page.

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TDI Form Number Description File Format Language
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
FIN311 Biographical Affidavit
Biographical Affidavit form to be completed by certain officers and directors of insurance companies; compliance with statute 		PDF English
FIN321 Company Licensing Fee Transmittal Form
 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
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
FIN407 Statutory Deposit Transaction Form
Statutory Deposit Transaction Form is submitted when a securities is deposited or withdrawn. 		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
FIN453 Declaration of Trust
Form to be executed for securities held on deposit. 		PDF English

For more information, contact: CompanyLicense@tdi.texas.gov