Workers' Compensation Self-Insurance Groups
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| TDI Form Number | Description | File Format | Language |
|---|---|---|---|
| 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 | |
| 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 |
For more information, contact: CompanyLicense@tdi.texas.gov