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Texas Department of Insurance
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Company Licensing and Registration Forms and Checklists

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TDI Form Number Description File Format Language
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
PDF English
FIN181 Biographical Affidavit for Captive Insurance Company
Biographical Affidavit form for individuals that oversee management of the Captive Insurance Company
PDF 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
PDF 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
PDF 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
PDF English
FIN187 Uniform Checklist for Reciprocal Jurisdiction Reinsurers
PDF English
FIN188 Application checklist for Certified Reinsurers
PDF English
FIN189 Certificate of Accredited Assuming Insurer (AR-1)
PDF English
FIN190 CR-1 Certificate of Certified Reinsurer
PDF 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)
PDF English
FIN197 Application Checklist for Accredited or Trusteed Assuming Insurer
PDF English
FIN300 Company Name Application
Application to reserve a company name
PDF English
FIN302 HMO Application for Certificate of Authority
Application for an HMO to do business in the state of Texas
PDF English
FIN306 Officers and Directors Page
Complete Listing of all Current Officers and Directors
PDF English
FIN307 Attorney-in-Fact and Underwriters Page
Lists the Attorney-in-Fact and Underwriters of Lloyds and Reciprocals
PDF English
FIN310 Application For A License As An Advisory Organization
Submit application to be licensed as an Advisory Organization
PDF English
FIN311 Biographical Affidavit
Biographical Affidavit form to be completed by certain officers and directors of insurance companies; compliance with statute
PDF English
FIN312 Attorney for Service form
Attorney for Service form
PDF English
FIN321 Company Licensing Fee Transmittal Form
Company Licensing and Registration Fee Transmittal Form to be submitted with filings.
PDF English
FIN322 Articles of Incorporation for a Texas Domestic P&C Company
Submitted as Articles of Incorporation for a Texas Domestic Property and Casualty Company
PDF English
FIN323 Articles of Incorporation for a Texas Domestic Life, Health and Accident Company
Submitted as Articles of Incorporation for a Texas Domestic Life, Health and Accident Company
PDF English
FIN324 Biographical Affidavit Update
submitted as notification of changes to biographical affidavit
PDF 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
PDF 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
PDF 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
PDF 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
PDF 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
PDF 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
PDF 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
PDF English
FIN351 Voluntary Dissolution Checklist
Instructions for a Texas-Domestic Company wanting to Dissolve and Cancel its Certificate of Authority
PDF English
FIN352 CCRC Biographical Affidavit Requirements
Biographical afffidavit requirements for Continuing Care Retirement Communities (CCRCs)
PDF English
FIN353 Biographical Affidavit and Fingerprint Requirements for Texas-Domestic Insurers
Requirements and instructions for submitting biographical affidavits and fingerprints for Texas-domestic insurers
PDF English
FIN354 Biographical Affidavit and Fingerprint Requirements for Foreign Insurers
Instructions and requirements for submitting biographical affidavit and fingerprints for foreign insurers
PDF 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)
PDF 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
PDF 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
PDF English
FIN358 HMO DBA Filing Checklist
Filing instructions relating to an HMO's DBA, Assumed Name, Trade Mark, Service Marks and Logos
PDF English
FIN359 HMO Home Office Change Checklist
Filing instruction related to a Health Maintenance Organization's subsequent filing for a home office change
PDF English
FIN360 HMO Name Change Checklist
Instructions related to a Health Maintenance Organization's subsequent filing for a name change
PDF English
FIN361 HMO Service Area Expansion
Filing instructions for a Health Maintenance Organization wishing to provide HMO coverage in additional counties
PDF English
FIN363 HMO Merger Checklist
Checklist and instructions for a Health Maintenance Organization's merger filing
PDF 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.
PDF 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.
PDF English
FIN367 Application for Reciprocal or Inter-Insurance Exchanges
Application to transact business as a reciprocal or inter-insurance exchange
PDF English
FIN368 Instructions for the Original Incorporation of Texas Lloyds Company
Instructions for the original incorporation of a Lloyds Company
PDF 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
PDF 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
PDF English
FIN371 Checklist for Change in Attorney in Fact for Reciprocals
Attorney-in-fact Change Checklist for Reciprocals (only)
PDF 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
PDF 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)
PDF English
FIN374 MEWA Application to Do Business
Application form to do business as a Multiple Employer Welfare Arrangement (MEWA)
PDF English
FIN375 Application for Initial Certificate of Authority (MEWA)
Multiple Employer Welfare Arrangement (MEWA) application for a temporary, or initial certificate of authority
PDF English
FIN376 MEWA Officers, Directors, and Trustees Page
Listing of all officers, directors, and trustees associated with the Multiple Employer Welfare Arrangement (MEWA)
PDF English
FIN377 Service of Process (MEWA)
Multiple Employer Welfare Arrangement (MEWA) Service of Process form
PDF English
FIN378 MEWA Annual Filing Checklist
Instructions for submitting annual filing for a Multiple Employer Welfare Arrangement (MEWA)
PDF 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
PDF 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
PDF English
FIN383 CCRC 2 - Continuing care provider
CCRC 2 - Application for Approval by the Commissioner for Release of Loan Reserve Fund Escrow Account Amounts
PDF English
FIN384 CCRC 3 - Officers and Directors Page
Continuing Care Retirement Community (CCRC) listing of all associated officers and directors, CCRC Form #3
PDF 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
PDF 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
PDF English
FIN387 CCRC 5 - Acknowledgement of Delivery of Disclosure Statement
Continuing Care Retirement Community (CCRC) resident's acknowledgement of delivery of Disclosure Statement, CCRC Form #5
PDF English
FIN388 CCRC 6 - Format for Disclosure Statement
Continuing Care Retirement Community (CCRC) detailed instructions and format for submitting Disclosure Statement, CCRC Form #6
WORD English
FIN389 CCRC Form #6A - CCRC Instructions for Preparation of Disclosure Statement
Continuing Care Retirement Community (CCRC) instructions for preparing Disclosure Statement filing, CCRC Form #6a
PDF English
FIN390 CCRC 7 - Change of Control Statement
PDF English
FIN391 CCRC 8 - Certification of Changes to Disclosure Statement
Continuing Care Retirement Community (CCRC) certification of changes made to the Disclosure Statement, CCRC Form #8
PDF English
FIN392 CCRC 9 - Notice of Request to Release Entrance Fee Escrow Funds
Continuing Care Retirement Community (CCRC) written notice of request to release entrance fee escrow funds, CCRC Form #9
PDF English
FIN393 CCRC 10 - Notice of Request to Release Funds from the Reserve Fund Escrow Account
Continuing Care Retirement Community (CCRC) written notice of request to release funds from the reserve funds escrow account, CCRC Form #10
PDF English
FIN394 CCRC 11 - Notice by Provider of Repayment of Previously Released Funds to Escrow Account
PDF English
FIN395 CCRC 12 - Affidavit of Repayment of Previously Released Funds to the Reserve Fund Escrow Account
PDF English
FIN396 CCRC 13 - Notice of Lien
PDF English
FIN397 CCRC 14 - Calculations Concerning Conditions
PDF English
FIN398 CCRC Name Change Checklist
Continuing Care Retirement Community (CCRC) charter amendment checklist to effect a name change
PDF English
FIN403 CCRC Release Escrow Checklist
PDF English
FIN407 Statutory Deposit Transaction Form
Statutory Deposit Transaction Form is submitted when a securities is deposited or withdrawn.
PDF 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
PDF 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
PDF 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
PDF 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.
PDF 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.
PDF 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.
PDF 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.
PDF 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.
PDF English
FIN435 Checklist for Placing an Initial Statutory Deposit
Checklist for an insurance company to initially place security funds on deposit.
PDF 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.
PDF English
FIN437 Checklist for Substituting Securities on Deposit
Checklist outlining documents required for an insurance company to substitute securities held on deposit.
PDF 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.
PDF English
FIN450 Joint Control Agreement for Lloyds
Form to be executed by Lloyds plan when placing required net assets as required by statute
PDF English
FIN453 Declaration of Trust
Form to be executed for securities held on deposit.
PDF English
FIN454 Checklist for Custodian Change for Securities on Deposit
PDF English
FIN455 Checklist for Renewing a Certificate of Deposit
PDF 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)
PDF 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.
PDF English
FIN590 Financial Analysis Fee Transmittal Form
for MEWAs and CCRCs
PDF English
FIN604 CCRC 1a - Application for authority to offer continuing care in residence services
PDF English
FIN605 CCRC 6B - Format for Disclosure Statement for Continuing Care in Residence
WORD English
FIN607 CCRC 14a - Provider request for release of continuing care residence entrance fee escrow funds
PDF English
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

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