Listing of all Texas Department of Insurance forms
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| TDI Form Number | Description | File Format | Language |
|---|---|---|---|
| AH001 |
Group Health Product Requirements Checklist |
English | |
| AH002 |
Group Health Large and Small Employer Requirements Checklist |
English | |
| AH003 |
Group Health Non-Employer or Member Association Checklist |
English | |
| AH004 |
Group Health Accident Only/Accidental Death and Dismemberment (AD&D) Checklist |
English | |
| AH005 |
Group Health Discretionary Group Checklist |
English | |
| AH008 |
Group Health Employer Market Form Filing Checklist - Figure 40, 42, 47, 48, and 50 |
English | |
| AH009 |
Group Health Specified Disease Checklist |
English | |
| AH010 |
Group Health Stop Loss Checklist |
English | |
| AH011 |
Group and Individual Dental and Vision Checklist |
English | |
| AH012 |
Group and Individual Long-Term Care Checklist |
English | |
| AH013 |
Group and Individual Health Supplemental Coverage Checklist |
English | |
| AH014 |
Group and Individual Health Medicare Supplement and Select Checklist |
English | |
| AH015 |
Individual Health Product Requirements Checklist |
English | |
| AH016 |
Individual Health Major Medical Checklist |
English | |
| AH017 |
Individual Health Limited Benefit Checklist |
English | |
| AH018 |
Individual Health Accident Only / Accidental Death and Dismemberment (AD&D) Checklist |
English | |
| AH020 |
Individual Health First Diagnosis or Critical Illness and Specified Disease Checklist |
English | |
| AH021 |
Individual Health Rate / Rate Increase Filing Requirements Checklist |
English | |
| AH022 |
Individual and Group Health Disability Income Protection Checklist |
English | |
| AH023 |
Individual and Group Health Hospital Indemnity Checklist |
English | |
| AH024 |
Individual Short-Term Recovery Care Checklist |
English | |
| AH025 (Fillable PDF) |
Balance billing waiver Fillable PDF version |
English | |
| AH025 |
Balance billing waiver |
English | |
| AS004 |
Accounting Texas Overhead Assessment |
English | |
| CP029 |
Health Insurance Mediation Request Form Request health insurance mediation |
English | |
| CP029-sp |
Obtenga ayuda si recibió una factura sorpresa de un proveedor de servicios médicos |
Spanish | |
| DWC001 |
Employer's First Report of Injury or Illness Rev. 10/05. This form is submitted by the carrier to DWC. |
English | |
| DWC001S |
Employer's First Report of Injury or Illness (for state employees) Rev. 10/05 |
English | |
| DWC002 |
Employer's Report for Reimbursement of Voluntary Payment Rev. 02/17 |
English | |
| DWC003 |
Employer’s wage statement Rev. 10/22 |
English | |
| DWC003ME |
Employee’s multiple employment wage statement Rev. 05/23 |
English | |
| DWC003MES |
Declaración de salario de múltiples trabajos del empleado Rev. 05/23 |
Spanish | |
| DWC003S |
Declaración de salarios del empleador Rev. 10/22 |
Spanish | |
| DWC003SD |
Employer’s wage statement for school districts Rev. 07/22 |
English | |
| DWC003SDS |
Declaración de salario del empleador para distritos escolares Rev. 07/22 |
Spanish | |
| DWC004 |
Employer's Contest of Compensability Rev. 11/08 |
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. |
English | |
| DWC005 |
Employer Notice of No Coverage or Termination of Coverage Rev. 02/18 - static version for mailing and faxing |
English | |
| DWC005s |
Aviso del Empleador de No Cobertura o de Cancelación de la Cobertura Rev. 02/18 |
Spanish | |
| DWC006 |
Supplemental Report of Injury Rev. 10/05 |
English | |
| DWC007 |
Employer’s report of noncovered employee’s work-related injury or illness Rev. 02/22 |
English | |
| DWC007S |
Reporte del empleador para lesiones o enfermedades relacionadas con el trabajo de los empleados sin cobertura Rev. 02/22 |
Spanish | |
| DWC008 |
Return-to-Work Reimbursement Program for Employers Rev. 04/10 |
English | |
| DWC020A |
Correction/Revision/Endorsement to Existing Policy Rev. 10/05 |
English | |
| DWC020SI |
Self-Insured Governmental Entity Coverage Information Rev. 08/12 - For help and an instructional video see “Electronic Filing - Online Forms” page. |
English | |
| DWC022 |
Request for a required medical examination (RME) Rev. 06/23 |
English | |
| DWC022S |
Solicitud para un examen médico requerido Rev. 06/23 |
Chinese | |
| DWC024 |
Benefit Dispute Agreement Rev. 11/17 |
English | |
| DWC024s |
Acuerdo para Disputa de Beneficios Rev. 11/17 |
Spanish | |
| DWC025 |
Benefit Dispute Settlement Rev. 11/17 |
English | |
| DWC025s |
Acuerdo por Disputa de Beneficios Rev. 11/17 |
Spanish | |
| DWC026 |
Request for Reimbursement of Payment Made by Health Care Insurer Rev. 01/15 |
English | |
| DWC027 |
Designation of insurance carrier’s Austin representative Rev. 03/22 |
English | |
| DWC029 |
Request for standard detailed data reports Rev. 03/22 |
English | |
| DWC031 |
Request to change payment period or purchase an annuity Rev. 06/23 |
English | |
| DWC031s |
Solicitud para cambiar el periodo de pago o para la compra de una anualidad Rev. 06/23 |
Spanish | |
| DWC032 |
Request for designated doctor examination Rev. 6/23, for use on or after 6/5/2023 |
English | |
| DWC032S |
Solicitud para obtener un examen por parte de un médico designado Rev. 06/23, para usar a partir del 5 de junio de 2023 |
Spanish | |
| DWC033 |
Request to reduce income benefits due to contribution Rev. 05/22 |
English | |
| DWC041 |
Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease Rev. 3/07 |
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 |
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. 03/16 |
English | |
| DWC042 |
Claim for Workers’ Compensation Death Benefits Rev. 03/16 |
WORD | English |
| DWC042S |
Reclamación para Obtener Beneficios de Compensación para Trabajadores por Causa de Muerte Rev. 3/16 |
Spanish | |
| DWC042S |
Reclamación para Obtener Beneficios de Compensación para Trabajadores por Causa de Muerte Rev. 3/16 |
WORD | Spanish |
| DWC044 |
Election to Engage in Arbitration Rev. 06/12 |
English | |
| DWC044S |
Elección para Participar en un Arbitraje Rev. 05/12 |
Spanish | |
| DWC045 |
Request to schedule, reschedule, or cancel a benefit review conference (BRC) Rev. 07/21 |
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 |
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 |
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 |
Spanish | |
| DWC045M |
Request to schedule, reschedule, or cancel a benefit review conference to appeal a medical fee dispute decision (BRC-MFD) Rev. 07/21 |
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 |
Spanish | |
| DWC046 |
Request to accelerate impairment income benefits Rev. 08/22 |
English | |
| DWC046S |
Solicitud para acelerar los beneficios de ingresos de impedimento Rev. 08/22 |
Spanish | |
| DWC047 |
Request to advance benefits Rev. 08/22 |
English | |
| DWC047S |
Solicitud para recibir beneficios por adelantado Rev. 08/22 |
Spanish | |
| DWC048 |
Request to get reimbursed for travel costs Rev. 07/21 |
English | |
| DWC048S |
Solicitud para obtener un reembolso por gastos de viaje Rev. 07/21 |
Spanish | |
| DWC049 |
Request to Schedule a Medical Contested Case Hearing (MCCH) Rev. 11/17 |
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 |
Spanish | |
| DWC051 |
Request for a lump sum payment of impairment income benefits (IIBs) Rev. 06/23 |
English | |
| DWC051S |
Solicitud para recibir un pago en suma total de los beneficios de ingresos de impedimento Rev. 06/23 |
Spanish | |
| DWC052 |
Application for Supplemental Income Benefits Rev. 02/17 |
English | |
| DWC052S |
Aplicación del trabajador para beneficios de ingresos suplementales Rev. 02/17 |
Spanish | |
| DWC053 |
Employee Request to Change Treating Doctor Rev. 03/12 |
English | |
| DWC053S |
Solicitud del Empleado para Cambiar de Médico de Tratamiento Rev. 03/12 |
Spanish | |
| DWC054 |
Notice to Employee: Intention to Request Division Permission to Adjust Benefits Rev. 02/17 |
English | |
| DWC054S |
Aviso al/a la Empleado/a: Intencion de Solicitar permiso a la División para Ajuste de Beneficios Rev. 02/17 |
Spanish | |
| DWC055 |
Request to Adjust Average Weekly Wage for Seasonal Employee Rev. 02/17 |
English | |
| DWC055S |
Solicitud de Ajuste al Salario Medio Semanal de un(a) Empleado/a de Temporada Rev. 02/17 |
Spanish | |
| DWC056 |
Carrier's Request for Seasonal Employee Wage Information from Texas Workforce Commission Records Rev. 02/17 |
English | |
| DWC057 |
Request to extend the date of maximum medical improvement for an approved spinal surgery Rev. 06/23 |
English | |
| DWC057S |
Solicitud para extender la fecha del mejoramiento máximo médico para una cirugía aprobada de la columna vertebral Rev. 06/23 |
Spanish | |
| DWC058 |
Request for Interlocutory Order Rev. 09/07 |
English | |
| DWC060 |
Medical Fee Dispute Resolution Request Rev. 02/21 |
English | |
| DWC060S |
Solicitud para Resolución de Disputas por Honorarios Médicos Rev. 02/21 |
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 |
English | |
| DWC066 |
Statement of Pharmacy Services Rev. 12/11 |
English | |
| DWC067 |
Designated doctor certification application Rev. 4/23, for use on or after 4/30/2023 |
English | |
| DWC068 |
Designated doctor examination data report Rev. 6/23, for use on or after 6/5/2023 |
English | |
| DWC069 |
Report of Medical Evaluation Rev. 1/15 |
English | |
| DWC070 |
Instructions For Completing The ADA J515 Dental Claim Form For Texas Workers' Compensation Claims Rev. 10/05 |
English | |
| DWC072 |
Medical Quality Review Panel Application Rev. 01/13 |
English | |
| DWC073 |
Work Status Report Rev. 09/19 |
English | |
| DWC073s |
Reporte de Estado de Trabajo Rev. 09/19 |
Spanish | |
| DWC074 |
Description of Injured Employee’s Employment Rev. 9/09 |
English | |
| DWC081 |
Agreement between general contractor and subcontractor to provide workers' compensation insurance Rev. 10/21 |
English | |
| DWC081S |
Acuerdo entre el contratista general y el subcontratista para proporcionar un seguro de compensación para trabajadores Rev. 10/21 |
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 |
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 |
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 |
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 |
Spanish | |
| DWC084 |
Exception to application of joint agreement to affirm independent relationship for certain building and construction workers Rev. 10/21 |
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 |
Spanish | |
| DWC085 |
Agreement between general contractor and subcontractor to establish independent relationship Rev. 10/21 |
English | |
| DWC085S |
Acuerdo entre el contratista general y el subcontratista para establecer una relación independiente Rev. 10/21 |
Spanish | |
| DWC095 |
SIF Reimbursement Request Form - Overturned Order or Designated Doctor Opinion Rev. 01/21 |
English | |
| DWC096 |
SIF Reimbursement Request Form – Refund of Death Benefits Rev. 01/21 |
English | |
| DWC097 |
SIF Reimbursement Request Form – Multiple Employment Rev. 01/21 |
English | |
| DWC098 |
SIF Reimbursement Request Form – Pharmaceutical Rev. 01/21 |
English | |
| DWC101 |
Program review report for rejected risk employers Rev. 11/21 |
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 |
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 |
English | |
| DWC104 |
Employer request for DWC safety consultation Rev. 11/21 |
WORD | English |
| DWC105 |
Accident prevention services worksheet Rev. 11/21 |
English | |
| DWC105 |
Accident prevention services worksheet Rev. 11/21 |
WORD | English |
| DWC105 |
Accident prevention services worksheet Rev. 11/21 |
English | |
| DWC105 |
Accident prevention services worksheet Rev. 11/21 |
WORD | English |
| DWC109 |
Accident prevention services annual report Rev. 11/21 |
English | |
| DWC109 |
Accident prevention services annual report Rev. 11/21 |
WORD | English |
| DWC109 |
Accident prevention services annual report Rev. 11/21 |
English | |
| DWC109 |
Accident prevention services annual report Rev. 11/21 |
WORD | English |
| DWC120 |
Designation of administrative services company administrator Rev. 03/22 |
English | |
| DWC121 |
Claim Administration Contact Information Rev. 3/20 |
English | |
| DWC150 |
Notice of Representation Rev. 12/16 |
English | |
| DWC150A |
Notice of Withdrawal of Representation Rev. 11/17 |
English | |
| DWC150AS |
Aviso de Anulación de Representación Legal Rev. 11/17 |
Spanish | |
| DWC150S |
Aviso de Representación Legal Rev. 12/16 |
Spanish | |
| DWC151 |
Attorney Application for Web Access Rev. 12/16 |
English | |
| DWC152 |
Application for Attorney Fees Rev. 11/17 |
English | |
| DWC153 |
Request for Record Check or Copies of Confidential Claim Information Rev. 02/21 |
English | |
| DWC153s |
Solicitud para Obtener Verificación de Expedientes o Copias de Información Confidencial de la Reclamación Rev. 02/21 |
Spanish | |
| DWC154 |
Workers' Compensation Complaint Form Rev. 03/16 |
English | |
| DWC154S |
Quejas de Compensación para Trabajadores Rev. 03/16 |
Spanish | |
| DWC156 |
Prospective employment authorization and certification Rev. 08/21 |
English | |
| DWC156S |
Certificación y autorización de un posible empleo Rev. 08/21 |
Spanish | |
| DWC205 |
Locations of Employer’s Business(es) Addendum to DWC Form-005 or DWC Form-020 - Rev. 11/10 |
English | |
| DWC205S |
Locaciones del Negocio(s) del Empleador Suplemento para el Formulario DWC005 o Formulario DWC020 - Rev. 11/10 |
Spanish | |
| EDI-02 |
Insurance carrier or trading partner medical electronic data interchange (EDI) profile Rev. 04/22 |
English | |
| EDI-03 |
Claim and medical EDI compliance coordinator and medical EDI trading partner notification Rev. 02/22 |
English | |
| FIN111 |
Health Entities Checklist Filing requirements |
English | |
| FIN116 |
HMO Supplement - Annual Information |
English | |
| FIN117 |
TDI Instructions for Filing CPA Audited Financial Reports |
English | |
| FIN119 |
Life, Accident and Health Insurers Filing requirements |
English | |
| FIN122 |
Property & Casualty Insurers Filing Requirements Checklist Filing requirements |
English | |
| FIN123 |
TDI Supplement Form for County Mutuals |
English | |
| FIN127 |
Title Checklist Filing requirements |
English | |
| FIN128 |
Annual Statement Blank - Farm Mutual Companies |
EXCEL | English |
| FIN128 |
Annual Statement Blank - Farm Mutual Companies |
English | |
| FIN138 |
Texas Supplemental A for County Mutuals Form Texas Supplemental "A" for County Mutuals Form |
English | |
| FIN139 |
Annual Operations Report Form FIN139 required to be filed annually by premium finance company, due April 1. Rev. 3/2021 |
English | |
| FIN145 |
Notice of intent to relocate books and records outside of Texas Form TDI BR-93 |
English | |
| FIN150 |
Texas Negotiated Deductible Workers' Compensation Form |
English | |
| FIN160, PF1 |
Application for An Insurance Premium Finance Company License (Form PF1) Premium Finance application for initial license to operate in Texas |
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 |
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 |
English | |
| FIN163, PF1C |
Premium Finance Renewal Application (Form PF1C) Premium Finance Renewal Application Form, required if renewing or not renewing |
English | |
| FIN164, PF2 |
Premium Finance List of Principals List all officers, directors and contact persons of Premium Finance Company |
English | |
| FIN165, PF3 |
Questionnaire - Premium Finance Applicant (Form PF3) Questionnaire to be completed by those wishing to obtain a premium finance company license |
English | |
| FIN166, PF4 |
Biographical Affidavit - Premium Finance Applicant (Form PF4) Form to be completed by each individual named on Form PF2. |
English | |
| FIN167, PF5 |
List of Other States of Licensure - Premium Finance Applicant (Form PF5) List of other states where Premium Finance Company is licensed |
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 |
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. |
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 |
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 |
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 |
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 |
English | |
| FIN174 |
Application for a Military Spouse to Operate as a Premium Finance Company Application for military spouse to operate as a Premium Finance Company in Texas |
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 | |
| FIN194 |
Annuity Transaction Disclosure form |
English | |
| FIN195 |
Consumer Refusal to Provide Information Before Buying an Annuity form |
English | |
| FIN196 |
Consumer Disclosure When Buying an Annuity Not Recommended by an Agent |
English | |
| FIN197 |
Application Checklist for Accredited or Trusteed Assuming Insurer |
English | |
| FIN202 |
Texas Policyholder Dividend Disbursement Notification/Application FIN 202 Texas Policyholder Dividend Disbursement Notification Application |
English | |
| FIN244 |
CPA Audited Financial Report - Intent Form Register a CPA to file an audited financial report |
English | |
| FIN246 |
Affidavit for Exemption from Filing CPA Audited Financial Report CPA Exemption Form |
English | |
| FIN251 |
Annual Statement Blank - Mutual Assessments, Burials, LMAs |
EXCEL | English |
| FIN251 |
Annual Statement Blank - Mutual Assessments, Burials, LMAs |
English | |
| FIN252 |
HMO Quarterly Supplement |
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 Company Licensing and Registration Fee Transmittal Form to be submitted with filings. |
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 | |
| FIN352 |
CCRC Biographical Affidavit Requirements Biographical affidavit requirements for Continuing Care Retirement Communities (CCRCs) |
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 | |
| FIN354 |
Biographical Affidavit and Fingerprint Requirements for Foreign Insurers Instructions and requirements for submitting biographical affidavit and fingerprints for foreign 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 | |
| FIN356 |
Biographical Affidavit and Fingerprint Requirements for Texas Lloyds and Reciprocal Insurers Instructions and requirements for submitting biographical affidavit and fingerprints for Texas Lloyds and Reciprocal insurers |
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 | |
| FIN381 |
CCRC Filing Requirements for Certificate of Authority Instructions for an entity wishing to operate as a Continuing Care Retirement Community (CCRC) in Texas |
English | |
| FIN382 |
CCRC 1 - Application for Certificate of Authority to do Business in Texas Continuing Care Retirement Community (CCRC) application for Certificate of Authority to do business in Texas, CCRC From #1 |
English | |
| FIN383 |
CCRC 2 - Continuing care provider CCRC 2 - Application for Approval by the Commissioner for Release of Loan Reserve Fund Escrow Account Amounts |
English | |
| FIN384 |
CCRC 3 - Officers and Directors Page Continuing Care Retirement Community (CCRC) listing of all associated officers and directors, CCRC Form #3 |
English | |
| FIN385 |
CCRC 4 - Biographical Data Form for a For-Profit CCRC Continuing Care Retirement Community (CCRC) biographical data form to be completed by any person serving as a board member for a for-profit CCRC, CCRC Form #4 |
English | |
| FIN386 |
CCRC 4A - CCRC Biographical Affidavit for a Not-For-Profit CCRC Continuing Care Retirement Community (CCRC) biographical data form to be completed by any person serving as a board member for a Not-for-Profit CCRC, CCRC Form #4a |
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 |
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 |
English | |
| FIN390 |
CCRC 7 - Change of Control Statement |
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 |
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 |
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 |
English | |
| FIN394 |
CCRC 11 - Notice by Provider of Repayment of Previously Released Funds to Escrow Account |
English | |
| FIN395 |
CCRC 12 - Affidavit of Repayment of Previously Released Funds to the Reserve Fund Escrow Account |
English | |
| FIN396 |
CCRC 13 - Notice of Lien |
English | |
| FIN397 |
CCRC 14 - Calculations Concerning Conditions |
English | |
| FIN398 |
CCRC Name Change Checklist Continuing Care Retirement Community (CCRC) charter amendment checklist to effect a name change |
English | |
| FIN403 |
CCRC Release Escrow Checklist |
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 |
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 | |
| 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 |
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 |
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 |
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. |
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 | |
| FIN464 |
Workers' Compensation Self-Insured Group (SIG) Administrator or Service Company Bond Format Instructions |
English | |
| FIN465 |
Workers Compensation Self-Insurance Group Application Application for Certificate of Approval to Conduct Workers Compensation Self-Insurance Group (SIG) Business |
English | |
| FIN466 |
Workers Compensation Self-Insurance Group (SIG) Application Checklist Application checklist for workers compensation Self-Insurance Groups (SIG) |
English | |
| FIN467 |
Workers Compensation Self-Insurance Group (SIG) Employer Membership Form Employer membership form for workers compensation Self-Insurance Groups |
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 |
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 |
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 |
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 |
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 |
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 |
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) |
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 |
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 |
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 |
English | |
| FIN478 |
Workers Compensation Self-Insurance Group (SIG) Financial Pro Forma Financial Pro Forma for a workers compensation Self-Insurance Group (SIG) |
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 |
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 |
English | |
| FIN481 |
Application for a Military Spouse to Act as an Administrator |
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 | |
| FIN483 |
Transactions Cash Receipts Transmittal Form |
English | |
| FIN484 |
Administrator Biographical Affidavit TPA form to be completed by each principal (i.e. officer, director, partner, sole proprietor, or owner) |
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. |
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. |
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. |
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 |
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 | |
| FIN491 |
Health Care Collaborative (HCC) Acquisition Form Department notification of an acquisition of a Health Care Collaborative |
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 |
English | |
| FIN493 |
Health Care Collaboratives Officers and Directors Page Health Care Collaborative Officer and Director Information |
English | |
| FIN494 |
Health Care Collaborative Payor Information Form Form used to provide HCC market power information |
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 |
English | |
| FIN496 |
Transmittal Checklist for Health Care Collaborative (HCC) Filings Health Care Collaborative Filing Transmittal Checklist |
English | |
| FIN497 |
Surrender of Third Party Administrator Certificate of Authority Notice of surrendering the COA or Authority for a Third Party Administrator |
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 |
English | |
| FIN499 |
Checklist for Administrator (TPA) Name Change Checklist to be submitted by a Third-Party Administrator to effect a name change. |
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. |
English | |
| FIN502 |
Notice of Change of Control Third-Party Administrator's authorized officer to complete this form for a change of control |
English | |
| FIN505 |
Licensing Corporate Insurance Agents Bond (aka Insurance Agency Bond) Method of showing proof of financial responsibility to obtain corporate license |
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. |
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. |
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. |
English | |
| FIN511 |
Licensing Reinsurance Intermediary Biographical Affidavit To register individuals to be associated to a Reinsurance Intermediary License. |
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. |
English | |
| FIN513 |
Licensing Reinsurance Intermediary Bond Method of showing proof of financial responsibility for a Reinsurance intermediary License. |
English | |
| FIN514 |
Specialty Insurance License Application Specialty Insurance License Application (fka Li004,LHL207) |
English | |
| FIN517 |
CE Exemption or Extension Application for licensee CE Exemption or Extension. Revised 07/2020 |
English | |
| FIN519 |
CE Automatic Fines Transmittal Continuing Education Fines. Revised 07/2020 |
English | |
| FIN520 |
CE provider information update |
English | |
| FIN521 |
Provider Audit Affidavit Used only by continuing education providers. Revised 01/2019 |
English | |
| FIN522 |
Licensee Request for Qualifying Credit TEXAS Qualifying Continuing Education Credit (fka LHL615). Revised 07/2020 |
English | |
| FIN523 |
Request for Association Credit Accepted by TDI Request for Association Credit (fka LHL617). Revised 01/2019 |
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 |
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 |
English | |
| FIN527 |
Discount Health Care Program Operator Registration Form Form for Registration as a Discount Health Care Program Operator. Rev. 01/2019 |
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. |
English | |
| FIN529 |
Life Agent License Use Affidavit Request CE waiver for life insurance not exceeding $25,000 agent licenses. |
English | |
| FIN530 |
Voluntary Surrender of Texas Insurance License |
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. |
English | |
| FIN533 |
Agent / Adjuster name or address change request form |
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. |
English | |
| FIN540 |
Agency address change request form |
English | |
| FIN548 |
Captive Management Company Biographical Certificate Form Form used for Captive Management Company's Biographical Certificate information. Follow the instructions within the form. |
English | |
| FIN549 |
Captive Management Company Registration Form Form used for Captive Management Company Registration information. Follow the instructions within the form. |
English | |
| FIN584 |
Form D Application - Prior Notice of Transaction |
English | |
| FIN585 |
Service Agreement Checklist Management, Service, Cost Sharing, Tax Allocation, Rental, Lease Agreement Checklist |
English | |
| FIN586 |
MGA Contract Review Checklist Managing General Agency Contract Review Checklist |
English | |
| FIN587 |
TPA Contract Review Checklist Third Party Administrator Contract Review Checklist |
English | |
| FIN588 |
Custodial Agreement Review Checklist |
English | |
| FIN590 |
Financial Analysis Fee Transmittal Form for MEWAs and CCRCs |
English | |
| FIN594 |
Application for Residency Change to Texas |
English | |
| FIN599 |
Cybersecurity Checklist |
English | |
| FIN604 |
CCRC 1a - Application for authority to offer continuing care in residence services |
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 |
English | |
| FIN609 |
Annual Verification of Fidelity Bond Coverage (HMO Employee) |
English | |
| FIN610 |
Annual Verification of Fidelity Bond Coverage (management contractor employees) |
English | |
| FIN611 |
RFQ Application – Claims Services |
English | |
| FIN612 |
RFQ Application – Information Technology Services |
English | |
| FIN613 |
RFQ Application – Legal Services |
English | |
| FIN614 |
RFQ Application – Reinsurance Services |
English | |
| FIN615 |
RFQ Application – Special Deputy Receiver |
English | |
| FIN616 |
RFQ Application – Accounting Services |
English | |
| FIN700 |
Appointment certification |
English | |
| FIN-NA |
CE Example Course Evaluation Sample Only |
English | |
| FINT01 |
Escrow Officer Name/Address Change Request |
English | |
| FINT03 |
Title insurance agent or direct operation renewal application |
English | |
| FINT05 |
CE Exemption/Extension Request |
English | |
| FINT08 |
Title insurance licensing biographical information |
English | |
| FINT09 |
Escrow officer appointment |
English | |
| FINT10 |
Title insurance agent or direct operation appointment |
English | |
| FINT22 |
Title licensee: continuing education credit request |
English | |
| FINT120 |
Abstract Plant Information Title Agency Abstract Plant Information |
English | |
| FINT122 |
Title Insurance Agent/Direct Operation Bond |
English | |
| FINT123 |
Escrow Officers Schedule Bond |
English | |
| FINT129 |
Title insurance agent or direct operation change request form Used for Title Agency information updates |
English | |
| FINT143 |
Application for title insurance agent or direct operation license |
English | |
| FR028 |
Suspected Insurance Fraud Report (SIU) Form |
English | |
| FR029 |
Suspected Insurance Fraud Reporting form for Consumers |
English | |
| FR029 |
Suspected Insurance Fraud Reporting form for Consumers (Spanish) |
Spanish | |
| HMO001 |
Consumer Choice Evidence of Coverage (EOC) Checklist - Individual Plans |
English | |
| HMO002 |
Consumer Choice Evidence of Coverage (EOC) Checklist - Large Employer and Conversion Plans |
English | |
| HMO003 |
Consumer Choice Evidence of Coverage (EOC) Checklist - Small Employer and Conversion Plans |
English | |
| HMO004 |
Evidence of Coverage (EOC) Checklist - Individual Plans |
English | |
| HMO005 |
Evidence of Coverage (EOC) Checklist - Large Employer and Conversion Plans |
English | |
| HMO006 |
Evidence of Coverage (EOC) Checklist - Small Employer and Conversion Plans |
English | |
| HMO007 |
Evidence of Coverage (EOC) Checklist - Single Health Care Service Plan - Dental Care |
English | |
| HMO008 |
Evidence of Coverage (EOC) Checklist - Single Health Care Service Plan - Vision Care |
English | |
| HR197 |
Acknowledgement of Mandatory Training |
English | |
| LAC001 |
Group Annuities Checklist |
English | |
| LAC002 |
Individual Deferred Annuities Checklist |
English | |
| LAC003 |
Single Premium Immediate Annuities Checklist |
English | |
| LAC004 |
Variable Annuities Checklist |
English | |
| LAC005 |
Group Life Insurance Checklist |
English | |
| LAC006 |
Individual Term and Whole Life Checklist |
English | |
| LAC007 |
Universal Life Insurance Checklist |
English | |
| LAC008 |
Variable Life Insurance Checklist |
English | |
| LAC009 |
Corporate Owned Life Insurance Checklist |
English | |
| LAC010 |
Fraternal Filings Checklist |
English | |
| LAC012 |
Private Placement Filings Checklist |
English | |
| LAC013 |
Annuity and Life Applications Checklist |
English | |
| LAC014 |
Life and Annuity Riders, Endorsements, and Amendments Checklist |
English | |
| LAC015 |
Accelerated Death Benefits Checklist |
English | |
| LAC016 |
Additional Insured's Checklist |
English | |
| LAC017 |
Guaranteed Living Benefits Checklist |
English | |
| LAC018 |
Index-Linked Crediting Features Checklist |
English | |
| LAC019 |
Life Exclusions Checklist |
English | |
| LAC020 |
Life Illustration Certification and Notification Checklist |
English | |
| LAC021 |
Market Value Adjustments Checklist |
English | |
| LAC022 |
Prepaid Funeral Filings Checklist |
English | |
| LAC023 |
Return of Premium Checklist |
English | |
| LAC024 |
Waiver of Premium Checklist |
English | |
| LAC025 |
Individual and Group Credit Life and Credit Accident and Health Insurance Checklist |
English | |
| LAC026 |
Life Settlement Forms Checklist |
English | |
| LAH301 |
Noninsurance Benefits Checklist |
English | |
| LAH302 |
Total and Partial Assumptions, Mergers, Name Changes, Redomestication, and Demutualization Form Filings Checklist |
English | |
| LAH303 |
Advertising Product Review Checklist |
English | |
| LAH310 |
Life and Health Transmittal Form |
English | |
| LAH311 |
Life, Health and HMO Miscellaneous Documents Transmittal Checklist |
English | |
| LAH312 |
HMO Transmittal Checklist and Certification Form |
English | |
| LAH313 |
Advertising Transmittal Checklist and Certification Form |
English | |
| LAH314 |
Advertising Annual Certification of Compliance |
English | |
| LAH321 |
Credit Insurance Deviation Request Form |
English | |
| LAH322 |
Actuarial Certification of Compliance for Indexed-Linked Annuities with an Additional Basis Point Reduction |
English | |
| LAH323 |
Life Settlement Provider Data Report |
English | |
| LAH345 |
Mandated Benefits and Mandated Offers Reporting Form |
English | |
| LAHR324 |
Notice and Consent for HIV-Related Testing |
English | |
| LAHR330 |
Small Employer Carrier Status Certification |
English | |
| LAHR334 |
Form Number 1212 Cert Actuarial Annual Small Employer Health Benefit Plan Actuarial Certification - Figure 47 |
English | |
| LAHR335 |
Form Number 1212 CERT DATA Annual Small Employer Health Benefit Plan Report |
English | |
| LAHR337 |
Large Employer Carrier Status Certification |
English | |
| LAHR339 |
CCP Figure 1 - Required Disclosure Statement For All Consumer Choice Health Benefit Plans |
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 |
English | |
| LHL005 |
URA Application Form Application to apply for URA Certification, renew a URA Certification or update a URA Certification. |
English | |
| LHL006 |
IRO Application Application to apply for IRO Certification, renew an IRO Certification or update an IRO Certification |
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. |
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 |
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. |
Spanish | |
| LHL011 |
Notice of Rescission of Preauthorization Exemption and Right to Request an Independent Review |
English | |
| LHL050 |
Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or after June 1, 2010 |
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. |
English | |
| LHL234 |
Application Package |
English | |
| LHL234a |
Other Professional Degrees Attachment A |
English | |
| LHL234b |
Other Post-Graduate Education Attachment B |
English | |
| LHL234c |
Other Work History Attachment C |
English | |
| LHL234d |
Other Current Hospital Affiliations Attachment D |
English | |
| LHL234e |
Other Previous Hospital Affiliations Attachment E |
English | |
| LHL234f |
Other Practice Locations Attachment F |
English | |
| LHL234g |
Malpractice Claims History Attachment G |
English | |
| LHL560 |
Long-Term Care Insurance Personal Worksheet |
English | |
| LHL561 |
Long-Term Care Insurance Potential Rate Increase Disclosure Form |
English | |
| LHL562 |
Long-Term Care Insurance Replacement and Lapse Reporting Form |
English | |
| LHL563 |
Long-Term Care Insurance Recission Reporting Form |
English | |
| LHL564 |
Long-Term Care Insurance Claim Denials Reporting Form |
English | |
| LHL565 |
Long-Term Care Insurance Policies Sold Reporting Form |
English | |
| LHL566 |
Long-Term Care Insurance Suitability Reporting Form |
English | |
| LHL567 |
Things To Know Before You Buy Long-Term Care Insurance |
English | |
| LHL568 |
Long-Term Care Insurance Suitability Letter |
English | |
| LHL569 |
Partnership Status Disclosure Notice for Long-Term Care Partnership Policies/Certificates |
English | |
| LHL570 |
Long-Term Care Partnership Program Insurer Certification Form |
English | |
| LHL572 |
Long-Term Care Partnership Agent Training Certification Form Annual Report |
English | |
| LHL573 |
Insurer Certification of Association Compliance with Marketing Standards for Long-Term Care Partnership and Non-Partnership Policies and Certificates |
English | |
| LHL610 |
Consumer Choice Health Benefit Plans Data Certification |
English | |
| LHL658 |
Application for Approval Exclusive Provider Benefit Plan (EPO) and Preferred Provider Benefit Plan (PPO) |
English | |
| LHL705 |
Workers’ Compensation Health Care Network Application |
English | |
| LHL706 |
Preferred Provider Benefit Plan (PPBP) and Exclusive Provider Benefit Plan (EPBP), Annual Report, Waiver Request, and Access Plan Checklist |
English | |
| LHL707 |
HMO Network Access Plan Requirements |
English | |
| LHL708 |
Workers' Compensation Network Access Plan Checklist WC Network Access Plan Checklist |
English | |
| LHL709 |
Certification of Independence and Qualifications of the Reviewer |
English | |
| LHL710 |
Holder of Bonds or Notes Over $100,000 |
English | |
| LHL711 |
Addendum to Biographical Affidavit |
English | |
| LHL712 |
IRO Notice of Decision Template - HC |
WORD | English |
| LHL713 |
IRO Notice of Decision Template - WC |
WORD | English |
| LHL715 |
Provider Network Contracting Entity Registration and Exemption of Affiliates Form PNCE Registration and Exemption Form |
English | |
| LHL716 |
Health Maintenance Organization Annual Network Adequacy Report and Access Plan Checklist |
English | |
| LHL717 |
Utilization Review Agent's (URA) Designated Contact for IRO Requests |
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 |
English | |
| LHL719 |
HMO Delegation Agreement Checklist |
English | |
| LHL720 |
Workers' Compensation Health Care Network Provider Contract Checklist |
English | |
| LHL721 |
Workers’ Compensation Network Contract with Insurance Carrier Contract Requirements Checklist |
English | |
| LHL722 |
Workers' Compensation Health Care Network Management Contract Checklist |
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 |
Vietnamese | |
| New Employee Notice English |
New Employee Notice covered and non-covered employers shall notify their employees of coverage status, in writing |
English | |
| New Employee Notice Spanish |
New Employee Notice Covered and non-covered employers shall notify their employees of coverage status in writing. |
Spanish | |
| NOFR001 |
Prior Authorization of Health Care Services |
English | |
| NOFR002 |
Texas Standard Prior Authorization Request Form for Prescription Drug Benefits |
English | |
| Notice 5 English |
Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read |
English | |
| Notice 5 Spanish |
Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read |
Spanish | |
| Notice 5 Vietnamese |
Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read |
Vietnamese | |
| Notice 6 English |
Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read |
English | |
| Notice 6 Spanish |
Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read |
Spanish | |
| Notice 6 Vietnamese |
Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read |
Vietnamese | |
| Notice 7 English |
Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read |
English | |
| Notice 7 Spanish |
Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read |
Spanish | |
| Notice 7 Vietnamese |
Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read |
Vietnamese | |
| Notice 8 English |
Required Workers’ Compensation Coverage (building or construction projects for governmental entities) |
English | |
| Notice 8 Spanish |
Required Workers’ Compensation Coverage (building or construction projects for governmental entities) |
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) |
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) |
Spanish | |
| Notice 10 English |
Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read |
English | |
| Notice 10 Spanish |
Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read |
Spanish | |
| Notice 10 Vietnamese |
Notice to Employees Concerning Workers' Compensation in Texas must be posted for employees to read |
Vietnamese | |
| PC068 |
Impact-Resistant Roofing Installation Form Roofing Installation Information and Certification for Reduction in Residential Insurance Premiums. |
English | |
| PC321 |
Amusement Ride Certificate of Inspection / Reinspection (Form AR-100) |
English | |
| PC322 |
Texas Amusement Ride Safety Inspection and Insurance Act Daily Inspection Record (Form AR-300) |
English | |
| PC323 |
Amusement Ride Schedule of Operations in Texas (Form AR-102) |
English | |
| PC324 |
Quarterly Injury Report Amusement Ride Safety Inspection and Insurance Act (Form AR-800) |
English | |
| PC325 |
Quarterly Governmental Action Report Amusement Ride Safety Inspection and Insurance Act (Form AR-801) |
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. |
English | |
| PC327 |
Certificate of Appliance-Related Water Damage Remediation |
English | |
| PC328 (CD-1) |
Use of Credit Information Disclosure |
English | |
| PC328 (CD-1) |
Divulgación del Uso de la Información de Crédito |
Spanish | |
| PC340 |
Certification of Sections 2251.251 - 2251.252 Exemption Compliance (EC-1) |
English | |
| PC350 (WPI-1) |
Application for Windstorm Inspection Certificate of Compliance |
English | |
| PC357 |
VIP Application for Residential Property Inspector License/Certificate |
English | |
| PC358 |
P&C Filing Transmittal Form |
English | |
| PC360 |
Company Certification Mortgage Guaranty Rate Filings |
English | |
| PC361 |
Credit Scoring Model Filing Form |
English | |
| PC365 |
Exhibit C Statewide Average Rate Level Information |
English | |
| PC366 |
Exhibit D Historical Experience |
English | |
| PC367 |
Exhibit E Expense Information - Including Disallowed Expense Adjustment |
English | |
| PC368 |
Exhibit F Expense Information - For Workers' Compensation and Mortgage Guaranty |
English | |
| PC369 |
Exhibit G Loss Costs Reference Information |
English | |
| PC370 |
Exhibit H Multi-Peril Rate Reference Information |
English | |
| PC371 |
Exhibit L Profit Provision Information |
English | |
| PC372 |
Certificate of Insurability (VIP1) |
English | |
| PC373 |
Residential Property Condition Evaluation Report (VIP2) |
English | |
| PC374 |
Territory Exhibit Display of Counties Affected by 15% Territory Rule |
English | |
| PC375 |
CS Exhibit Support for use of Credit Scoring |
English | |
| PC376 |
Exhibit WC Workers' Compensation |
English | |
| PC377 |
Territory Exhibit Support for Territorial Deviations |
English | |
| PC381 |
Public Information Notice for Amusement Rides |
English | |
| PC382 (WPI-2-BC-6) |
Inspection Verification For projects that began construction between January 1, 2017, and August 31, 2020 |
English | |
| PC390 |
Loss Control Representative Qualification Review |
English | |
| PC391 |
Field Safety Representative with a Specialty in Hospitals Qualification Review |
English | |
| PC400 |
Contact Information Update Request To be completed by Appointed Qualified Inspectors only |
English | |
| PC404 |
Compliance Questionnaire - Use of Credit Information |
WORD | English |
| PC404 |
Compliance Questionnaire - Use of Credit Information |
English | |
| PC405 |
CM Exhibit Additional Information for Certain County Mutuals |
English | |
| PC406 |
Appraisal Umpire Roster Application |
English | |
| PC407 |
Mediator Roster Application |
English | |
| PC410 |
2018 TTIGA Guaranty Assessment Recoupment Charge Remittance Form (Effective January 1 - December 31, 2018) |
English | |
| PC411 |
Title Agent's Unencumbered Assets Certification (Form T-S1) |
English | |
| PC412 |
Tripartite Agreement (Form T-S2) |
English | |
| PC413 |
Solvency Account Release Request (Form T-S3) |
English | |
| PC414 |
Annual Report of Title Company's Officers Authorized to Provide Information on Agent Financial Matters (Form T-S4) |
English | |
| PC415 |
Financial Matter Disclosure Report (Form T-S4-A) |
English | |
| PC416 |
Title Agent Certification of Agent's Quarterly Tax Reports (Form T-S5) |
English | |
| PC417 |
Texas Title Insurance Agent's Minimum Capitalization Bond |
English | |
| PC418 |
Prescribed Auto ID Card Form (28 TAC §5.204) |
English | |
| PC419 |
Certificate of Insurance Filing Transmittal Form |
English | |
| PC420 |
Exhibit A Rate Filing Checklist |
English | |
| PC421 |
Exhibit B SERFF Rate Data |
English | |
| PC422 |
County Exhibit Average Premium Change by County |
English | |
| PC423 |
VIP Renewal for Residential Property Inspector License/Certificate |
English | |
| PC424 |
Form usage table — short version (up to 90 forms) Optional/Mandatory/Conditional Mandatory |
English | |
| PC425 (AQI-1) |
Application for Appointment as a Qualified Inspector |
English | |
| PC426 (AQI-R) |
Application Renewal for Appointment as a Qualified Inspector |
English | |
| PC427 |
Form usage table — long version (up to 470 forms) Optional/Mandatory/Conditional Mandatory |
English | |
| PC428 (WPI-2-BC-5) |
Inspection Verification For ongoing improvements for construction that began between January 1, 2008, and December 31, 2016. |
English | |
| PC434 (WPI-2E) |
Application for Certificate of Compliance For completed improvements. |
English | |
| PC436 (WPI-2-BC-7) |
Inspection Verification For ongoing improvements for construction that began on or after April 1, 2020 (2018 building code). |
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. 07/21 |
WORD | English |
| PLN12S |
Notice of Potential Entitlement to Workers’ Compensation Death Benefits Rev. 07/21 |
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 |
English | |
| SF026 |
Fire Extinguisher License Application |
English | |
| SF027 |
Fire Extinguisher Apprentice Permit Application |
English | |
| SF028 |
Application to Revise or Transfer All Types of Fire Extinguisher Licenses |
English | |
| SF031 |
Fire Alarm Certificate of Registration Application New Companies and New Branch Offices |
English | |
| SF032 |
Individual Application for All Types of Fire Alarm Licenses |
English | |
| SF033 |
Application to Revise or Transfer All Types of Fire Alarm Licenses |
English | |
| SF035 |
Fire Alarm Installation Certificate |
English | |
| SF036 |
Fire Sprinkler Responsible Managing Employee (RME) License Application |
English | |
| SF037 |
Fire Sprinkler Certificate of Registration Application New Companies |
English | |
| SF038 |
Revision/Transfer Application for Individuals |
English | |
| SF041 |
Contractor's Material and Test Certification for Aboveground Piping |
English | |
| SF042 |
Contractor's Material and Test Certification for Underground Piping |
English | |
| SF043 |
Application for Fireworks License and / or Permit Distributors, Jobbers, Manufacturers, Wildlife, Agricultural and Industrial Permit |
English | |
| SF044 |
Application for Class B Fireworks Singular or Multiple Display Permit |
English | |
| SF045 |
Pyrotechnic, Special Effects and Flame Effects Operator's License Application |
English | |
| SF047 |
Application for Retail Fireworks Permit |
English | |
| SF054 |
Branch Office Update Form |
English | |
| SF084 |
Fire Alarm Certificate of Registration Renewal Application |
English | |
| SF086 |
Renewal Application - Fire Extinguisher Certificate of Registration Renewal of companies and branch offices |
English | |
| SF087 |
Renewal Application - Hydrostatic Testing Certificate of Registration |
English | |
| SF088 |
Renewal Application - Fire Sprinkler Certificate of Registration |
English | |
| SF091 |
Renewal Application - Fireworks License Distributors, Jobbers, Manufacturers |
English | |
| SF094 |
Individual License Renewal Application for All Types of Fire Alarm Licenses |
English | |
| SF099 |
Renewal Application - Fire Extinguisher License Renewal of Individual Licenses |
English | |
| SF100 |
Renewal Application - Fire Sprinkler Responsible Managing Employee |
English | |
| SF104 |
Renewal Application - Fireworks Operator's License |
English | |
| SF146 |
Texas Fire Department Identification (FDID) Number Request Application |
English | |
| SF205 |
Fire Extinguisher System Installation Certification |
English | |
| SF222 |
Retail Fireworks Indoor Site Information Form |
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). |
English | |
| SF227 |
Company Information Update Form To update company address and authorized signatures |
English | |
| SF228 |
Licensed Employee Termination Notice |
English | |
| SF230 |
Fireworks Company Information Update Form |
English | |
| SF246 |
Fire Alarm Training School Approval Application Alarm Training Form |
English | |
| SF247 |
Fire Alarm Instructor Approval Application Alarm Instructor Form |
English | |
| SF250 |
Fire Standard Compliant Cigarette Manufacturer Form Certification by Manufacturer |
English | |
| SF251 |
Fire Standard Compliant Cigarette Manufacturer Form Application for Fire Standard Compliant Cigarette Marking Approval |
English | |
| SF254 |
Fire Alarm Training School Renewal Application |
English | |
| SF255 |
Fire Alarm Instructor Renewal Application |
English | |
| SF259 |
Fire Safety Inspection Request Form |
English | |
| SF261 |
Supplemental Criminal History Information |
English | |
| SF265 |
Application Fee Exemption Form - Armed Services |
English | |
| SF266 |
Fire Suppression Rating Oversight Complaint Form |
English | |
| SF272 |
Application to Revise All Types of Individual Fireworks Licenses |
English | |
| SF300 |
Course Location and Schedule |
English | |
| SF400 |
Extinguisher Fixed Support System |
English | |
| SF500 |
Applicant's Employer Information |
English | |
| SF525 |
Fire Sprinkler Non-Resident Responsible Managing Employee (RME-G) Application Questions |
English | |
| SF550 |
Fire Sprinkler Non-Resident Responsible Managing Employee-Underground Fire Main (RME-U) Application Questions |
English | |
| SF600 |
Fireworks Online Application Supplement |
English | |
| SN002 |
Notice to HMO Enrollees: Have a complaint about your HMO? |
English | |
| SN002s |
¿Tiene una queja relacionada con su HMO? |
Spanish | |
| SN003 |
Workers Comp Network Sample Contingency Plan |
English | |
| SN004 |
Workers Comp Net Sample Employee Acknowledgment Form |
English | |
| SN005 |
Workers Comp Net Employee Acknowledgment Form |
Spanish | |
| SN006 |
Workers Comp Net Sample Employee Acknowledgment Form - Chinese |
Chinese | |
| SN007 |
Workers Comp Net Sample Employee Acknowledgment Form |
Vietnamese | |
| SN008 |
Workers Comp Network Sample QI Report |
English | |
| SN009 |
Sample URA Adverse Determination Notice, Health |
English | |
| SN010 |
Sample URA Adverse Determination Notice, Specialty Health |
English | |
| SN011 |
Sample URA Adverse Determination Notice, Workers Comp Net |
English | |
| SN012 |
Sample URA Adverse Determination Notice, Workers Comp Non-Network |
English | |
| SN013 |
Contract List |
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 |
English | |
| SN016 |
Sample Network Adequacy Contracted Provider List |
EXCEL | English |
| SN017 |
Sample Network Adequacy Access Plan |
EXCEL | English |
| TPA Annual Report Workbook |
TPA Annual Report Workbook Compilation of TPA Annual Report Forms FIN486-488, which can be submitted to meet TPA Annual Report requirements. |
EXCEL | English |
| Sample Notice |
Notice of Underpayment of Income Benefits Rev. 12/11 |
English | |
| Sample Notice |
Aviso de Pago Insuficiente de los Beneficios de Ingresos Rev. 12/11 |
Spanish |
For more information, contact: FormsMgr@tdi.texas.gov