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Texas Department of Insurance
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Life and Health – Other Forms

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TDI Form Number Description File Format Language
LAC010 Fraternal Filings Checklist
PDF English
LAC012 Private Placement Filings Checklist
PDF English
LAC014 Life and Annuity Riders, Endorsements, and Amendments Checklist
PDF English
LAC018 Index-Linked Crediting Features Checklist
PDF English
LAC020 Life Illustration Certification and Notification Checklist
PDF English
LAC022 Prepaid Funeral Filings Checklist
PDF English
LAH301 Noninsurance Benefits Checklist
PDF English
LAH302 Total and Partial Assumptions, Mergers, Name Changes, Redomestication, and Demutualization Form Filings Checklist
PDF English
LAH303 Advertising Product Review Checklist
PDF English
LAH345 Mandated Benefits and Mandated Offers Reporting Form
PDF English
LAHR324 Notice and Consent for HIV-Related Testing
PDF English
LAHR339 CCP Figure 1 - Required Disclosure Statement For All Consumer Choice Health Benefit Plans
PDF English
LAHR339 - Example 1 Employer example of LAHR339 (Form CCP1)
WORD English
LAHR339 - Example 2 Healthcare.gov example of LAHR339 (Form CCP1)
WORD English
LHL050 Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or after June 1, 2010
PDF 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.
PDF English
LHL560 Long-Term Care Insurance Personal Worksheet
PDF English
LHL561 Long-Term Care Insurance Potential Rate Increase Disclosure Form
PDF English
LHL562 Long-Term Care Insurance Replacement and Lapse Reporting Form
PDF English
LHL563 Long-Term Care Insurance Recission Reporting Form
PDF English
LHL564 Long-Term Care Insurance Claim Denials Reporting Form
PDF English
LHL565 Long-Term Care Insurance Policies Sold Reporting Form
PDF English
LHL566 Long-Term Care Insurance Suitability Reporting Form
PDF English
LHL567 Things To Know Before You Buy Long-Term Care Insurance
PDF English
LHL568 Long-Term Care Insurance Suitability Letter
PDF English
LHL569 Partnership Status Disclosure Notice for Long-Term Care Partnership Policies/Certificates
PDF English
LHL570 Long-Term Care Partnership Program Insurer Certification Form
PDF English
LHL572 Long-Term Care Partnership Agent Training Certification Form Annual Report
PDF English
LHL573 Insurer Certification of Association Compliance with Marketing Standards for Long-Term Care Partnership and Non-Partnership Policies and Certificates
PDF English
NOFR001 Prior Authorization of Health Care Services
PDF English
NOFR002 Texas Standard Prior Authorization Request Form for Prescription Drug Benefits
Current form - You can use this version until November 9, 2022.
PDF English
NOFR002 Texas Standard Prior Authorization Request Form for Prescription Drug Benefits
Revised form - You can use this version starting August 11, 2022.
PDF English

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