Listing of all TDI forms
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| TDI form number | Description | 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 | |
| AH005 |
Group Health Discretionary Group Checklist |
English | |
| AH008 |
Group Health Employer Market Form Filing Checklist - Figure 40, 42, 47, 48, and 50 |
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 and Group Health Accident Only/ Accidental Death & Dismemberment Checklist |
English | |
| AH020 |
Individual and Group 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 | |
| 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 | |
| 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 |
Governmental entity coverage information Rev. 08/24 |
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 |
English | |
| DWC032S |
Solicitud para obtener un examen por parte de un médico designado Rev. 06/23 |
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. 12/23 |
English | |
| DWC042S |
Reclamación para obtener beneficios de compensación para trabajadores por causa de muerte Rev. 12/23 |
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 |
Supplemental Income Benefits (SIBs) Application Rev. 07/24 |
English | |
| DWC052S |
Solicitud para recibir beneficios de ingresos suplementarios (SIBs) Rev. 07/24 |
English | |
| 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 |
English | |
| DWC068 |
Designated doctor examination data report Rev. 6/23 |
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. 07/24 |
English | |
| DWC105 |
Accident prevention services worksheet Rev. 07/24 |
WORD | English |
| DWC105 |
Accident prevention services worksheet Rev. 07/24 |
English | |
| DWC105 |
Accident prevention services worksheet Rev. 07/24 |
WORD | English |
| DWC109 |
Accident prevention services annual report Rev. 07/24 |
English | |
| DWC109 |
Accident prevention services annual report Rev. 07/24 |
WORD | English |
| DWC109 |
Accident prevention services annual report Rev. 07/24 |
English | |
| DWC109 |
Accident prevention services annual report Rev. 07/24 |
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 | |
| 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 | |
| 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 |
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 | |
| 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 | |
| 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 (Li004, LHL207) |
English | |
| FIN517 |
CE Exemption or Extension Application for licensee CE Exemption or Extension. Revised 07/2020 |
English | |
| FIN519 |
CE Automatic Fines Transmittal Use to pay CE fines. Pay online with a Sircon account for fastest processing. (www.sircon.com/login.jsp) |
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 Form for individuals changing state of residency to TX. Agencies must apply for a resident license via Sircon or the National Insurance Producer Registry. |
English | |
| FIN599 |
Cybersecurity Checklist |
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 Renew online at Sircon and follow the TDI tutorials before starting the renewal process. |
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 Apply online at www.Sircon.com and follow tutorials provided on TDI website for fastest processing. |
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 | |
| 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 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 | |
| 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 |
| LHL714 |
IRO Notice of Decision Template - Rescission |
WORD | English |
| LHL715 |
Provider Network Contracting Entity Registration and Exemption of Affiliates Form PNCE Registration and Exemption Form |
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 Rate 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 | |
| PC437 |
Third Party Evaluation Reports Request to post on TDI website |
English | |
| PLN01 |
Notice of Denial of Compensability/Liability and Refusal to Pay Benefits Rev. 07/21 |
WORD | English |
| PLN01S |
Notice of Denial of Compensability/Liability and Refusal to Pay Benefits Rev. 07/21 |
WORD | Spanish |
| PLN02A |
Notice of First Temporary Income Benefit Payment Rev. 07/21 |
WORD | English |
| PLN02AS |
Notice of First Temporary Income Benefit Payment Rev. 07/21 |
WORD | Spanish |
| PLN02B |
Notice of first payment of income benefits on an acquired claim Rev. 07/23 |
WORD | English |
| PLN02BS |
Notice of first payment of income benefits on an acquired claim Rev. 07/23 |
WORD | Spanish |
| PLN03A |
Notice of Maximum Medical Improvement and No Permanent Impairment Rev. 07/21 |
WORD | English |
| PLN03AS |
Notice of Maximum Medical Improvement and No Permanent Impairment Rev. 07/21 |
WORD | Spanish |
| PLN03B |
Notice of Maximum Medical Improvement and Permanent Impairment Rev. 07/21 |
WORD | English |
| PLN03BS |
Notice of Maximum Medical Improvement and Permanent Impairment Rev. 07/21 |
WORD | Spanish |
| PLN03C |
Notice of Maximum Medical Improvement and Estimated Permanent Impairment Rev. 07/21 |
WORD | English |
| PLN03CS |
Notice of Maximum Medical Improvement and Estimated Permanent Impairment Rev. 07/21 |
WORD | Spanish |
| PLN04 |
Notice of Eligibility for Lifetime Income Benefits Rev. 07/21 |
WORD | English |
| PLN04S |
Notice of Eligibility for Lifetime Income Benefits Rev. 07/21 |
WORD | Spanish |
| PLN05 |
Notice of First Death Benefit Payment Rev. 07/21 |
WORD | English |
| PLN05S |
Notice of First Death Benefit Payment Rev. 07/21 |
WORD | Spanish |
| PLN06 |
Notice of Employer Full Salary Payment Rev. 07/21 |
WORD | English |
| PLN06S |
Notice of Employer Full Salary Payment Rev. 07/21 |
WORD | Spanish |
| PLN07 |
Notice of Change of Indemnity Benefit Type Rev. 07/21 |
WORD | English |
| PLN07S |
Notice of Change of Indemnity Benefit Type Rev. 07/21 |
WORD | Spanish |
| PLN08 |
Notice of Change in Amount of Indemnity Benefit Payment Rev. 07/23 |
WORD | English |
| PLN08S |
Notice of Change in Amount of Indemnity Benefit Payment Rev. 07/23 |
WORD | Spanish |
| PLN09 |
Notice of Suspension of Indemnity Benefits Rev. 07/21 |
WORD | English |
| PLN09S |
Notice of Suspension of Indemnity Benefits Rev. 07/21 |
WORD | Spanish |
| PLN10A |
Notice of reinstatement of indemnity benefits Rev. 07/23 |
WORD | English |
| PLN10AS |
Notice of reinstatement of indemnity benefits Rev. 07/23 |
WORD | Spanish |
| PLN10B |
Notice of lump sum payment of income or death benefits Rev. 07/23 |
WORD | English |
| PLN10BS |
Notice of lump sum payment of income or death benefits Rev. 07/23 |
WORD | Spanish |
| PLN11 |
Notice of Disputed Issues and Refusal to Pay Benefits Rev. 07/23 |
WORD | English |
| PLN11S |
Notice of Disputed Issues and Refusal to Pay Benefits Rev. 07/23 |
WORD | Spanish |
| PLN12 |
Notice of Potential Entitlement to Workers’ Compensation Death Benefits Rev. 12/23 |
WORD | English |
| PLN12S |
Notice of Potential Entitlement to Workers’ Compensation Death Benefits Rev. 12/23 |
WORD | Spanish |
| PLN14 |
Notice of Continuing Investigation Rev. 07/23 |
WORD | English |
| PLN14S |
Notificación de Investigación en Curso Rev. 07/23 |
WORD | Spanish |
| SF025 |
Fire Extinguisher Certificate of Registration Application New Companies and New Branch Offices |
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 | |
| SN019 |
HMO Major Medical Access Plan Template |
EXCEL | English |
| SN020 |
HMO Attempt to Contract Template |
EXCEL | English |
| SN021 |
HMO Dental Access Plan Template |
EXCEL | English |
| SN022 |
HMO Provider List Template |
EXCEL | English |
| SN023 |
HMO Vision Access Plan Template |
EXCEL | English |
| SN024 |
HMO Vision Provider List Template |
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