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Texas Department of Insurance
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Accident and Health Checklists, Forms and Rate Report

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TDI form number Description Format Language
AH001 Group Health Product Requirements Checklist
 PDF English
AH002 Group Health Large and Small Employer Requirements Checklist
 PDF English
AH003 Group Health Non-Employer or Member Association Checklist
 PDF English
AH005 Group Health Discretionary Group Checklist
 PDF English
AH008 Group Health Employer Market Form Filing Checklist - Figure 40, 42, 47, 48, and 50
 PDF English
AH010 Group Health Stop Loss Checklist
 PDF English
AH011 Group and Individual Dental and Vision Checklist
 PDF English
AH012 Group and Individual Long-Term Care Checklist
 PDF English
AH013 Group and Individual Health Supplemental Coverage Checklist
 PDF English
AH014 Group and Individual Health Medicare Supplement and Select Checklist
 PDF English
AH015 Individual Health Product Requirements Checklist
 PDF English
AH016 Individual Health Major Medical Checklist
 PDF English
AH017 Individual Health Limited Benefit Checklist
 PDF English
AH018 Individual and Group Health Accident Only/ Accidental Death & Dismemberment Checklist
 PDF English
AH020 Individual and Group Health First Diagnosis or Critical Illness and Specified Disease Checklist
 PDF English
AH022 Individual and Group Health Disability Income Protection Checklist
 PDF English
AH023 Individual and Group Health Hospital Indemnity Checklist
 PDF English
AH024 Individual Short-Term Recovery Care Checklist
 PDF English
AH025 (Fillable PDF) Balance billing waiver
Fillable PDF version 		PDF English
AH025 Balance billing waiver
 PDF English
AH026 Exhibit A — Permissible Exclusions in Individual Accident and Health Policies
PDF English
LAHR330 Small Employer Carrier Status Certification
 PDF English
LAHR334 Form Number 1212 Cert Actuarial Annual Small Employer Health Benefit Plan Actuarial Certification - Figure 47
 PDF English
LAHR335 Form Number 1212 CERT DATA Annual Small Employer Health Benefit Plan Report
 PDF English
LAHR337 Large Employer Carrier Status Certification
 PDF English
LHL610 Consumer Choice Health Benefit Plans Data Certification
 PDF English

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