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Texas Department of Insurance
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Financial Analysis

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TDI Form Number Description File Format Language
FIN111 Health Entities Checklist
Filing requirements
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 Checklist
Filing requirements
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
FIN145 Guidelines and Application for Approval to Maintain Books and Records Outside of Texas
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
FIN383 CCRC 2 - Continuing care provider
CCRC 2 - Application for Approval by the Commissioner for Release of Loan Reserve Fund Escrow Account Amounts
PDF English
FIN387 CCRC 5 - Acknowledgement of Delivery of Disclosure Statement
Continuing Care Retirement Community (CCRC) resident's acknowledgement of delivery of Disclosure Statement, CCRC Form #5
PDF English
FIN388 CCRC 6 - Format for Disclosure Statement
Continuing Care Retirement Community (CCRC) detailed instructions and format for submitting Disclosure Statement, CCRC Form #6
WORD English
FIN389 CCRC Form #6A - CCRC Instructions for Preparation of Disclosure Statement
Continuing Care Retirement Community (CCRC) instructions for preparing Disclosure Statement filing, CCRC Form #6a
PDF English
FIN391 CCRC 8 - Certification of Changes to Disclosure Statement
Continuing Care Retirement Community (CCRC) certification of changes made to the Disclosure Statement, CCRC Form #8
PDF English
FIN392 CCRC 9 - Notice of Request to Release Entrance Fee Escrow Funds
Continuing Care Retirement Community (CCRC) written notice of request to release entrance fee escrow funds, CCRC Form #9
PDF English
FIN393 CCRC 10 - Notice of Request to Release Funds from the Reserve Fund Escrow Account
Continuing Care Retirement Community (CCRC) written notice of request to release funds from the reserve funds escrow account, CCRC Form #10
PDF English
FIN394 CCRC 11 - Notice by Provider of Repayment of Previously Released Funds to Escrow Account
PDF English
FIN395 CCRC 12 - Affidavit of Repayment of Previously Released Funds to the Reserve Fund Escrow Account
PDF English
FIN396 CCRC 13 - Notice of Lien
PDF English
FIN397 CCRC 14 - Calculations Concerning Conditions
PDF English
FIN403 CCRC Release Escrow Checklist
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
FIN599 Cybersecurity Checklist
PDF English
FIN605 CCRC 6B - Format for Disclosure Statement for Continuing Care in Residence
WORD English
FIN607 CCRC 14a - Provider request for release of continuing care residence entrance fee escrow funds
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

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