| 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 |
| HMO001
|
Consumer Choice Evidence of Coverage (EOC) Checklist - Individual Plans
|
PDF |
English |
| HMO002
|
Consumer Choice Evidence of Coverage (EOC) Checklist - Large Employer and Conversion Plans
|
PDF |
English |
| HMO003
|
Consumer Choice Evidence of Coverage (EOC) Checklist - Small Employer and Conversion Plans
|
PDF |
English |
| HMO004
|
Evidence of Coverage (EOC) Checklist - Individual Plans
|
PDF |
English |
| HMO005
|
Evidence of Coverage (EOC) Checklist - Large Employer and Conversion Plans
|
PDF |
English |
| HMO006
|
Evidence of Coverage (EOC) Checklist - Small Employer and Conversion Plans
|
PDF |
English |
| HMO007
|
Evidence of Coverage (EOC) Checklist - Single Health Care Service Plan - Dental Care
|
PDF |
English |
| HMO008
|
Evidence of Coverage (EOC) Checklist - Single Health Care Service Plan - Vision Care
|
PDF |
English |
| LAC001
|
Group Annuities Checklist
|
PDF |
English |
| LAC002
|
Individual Deferred Annuities Checklist
|
PDF |
English |
| LAC003
|
Single Premium Immediate Annuities Checklist
|
PDF |
English |
| LAC004
|
Variable Annuities Checklist
|
PDF |
English |
| LAC005
|
Group Life Insurance Checklist
|
PDF |
English |
| LAC006
|
Individual Term and Whole Life Checklist
|
PDF |
English |
| LAC007
|
Universal Life Insurance Checklist
|
PDF |
English |
| LAC008
|
Variable Life Insurance Checklist
|
PDF |
English |
| LAC009
|
Corporate Owned Life Insurance Checklist
|
PDF |
English |
| LAC010
|
Fraternal Filings Checklist
|
PDF |
English |
| LAC012
|
Private Placement Filings Checklist
|
PDF |
English |
| LAC013
|
Annuity and Life Applications Checklist
|
PDF |
English |
| LAC014
|
Life and Annuity Riders, Endorsements, and Amendments Checklist
|
PDF |
English |
| LAC015
|
Accelerated Death Benefits Checklist
|
PDF |
English |
| LAC016
|
Additional Insured's Checklist
|
PDF |
English |
| LAC017
|
Guaranteed Living Benefits Checklist
|
PDF |
English |
| LAC018
|
Index-Linked Crediting Features Checklist
|
PDF |
English |
| LAC019
|
Life Exclusions Checklist
|
PDF |
English |
| LAC020
|
Life Illustration Certification and Notification Checklist
|
PDF |
English |
| LAC021
|
Market Value Adjustments Checklist
|
PDF |
English |
| LAC022
|
Prepaid Funeral Filings Checklist
|
PDF |
English |
| LAC023
|
Return of Premium Checklist
|
PDF |
English |
| LAC024
|
Waiver of Premium Checklist
|
PDF |
English |
| LAC025
|
Individual and Group Credit Life and Credit Accident and Health Insurance Checklist
|
PDF |
English |
| LAC026
|
Life Settlement Forms Checklist
|
PDF |
English |
| LAC028
|
Replacement of Life Insurance or Annuities
|
PDF |
English |
| LAC029
|
Notice Regarding Replacement - Replacing Your Life Insurance Policy or Annuity
|
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 |
| LAH310
|
Life and Health Transmittal Form
|
PDF |
English |
| LAH311
|
Life, Health and HMO Miscellaneous Documents Transmittal Checklist
|
PDF |
English |
| LAH312
|
HMO Transmittal Form
|
PDF |
English |
| LAH313
|
Advertising Transmittal Checklist and Certification Form
|
PDF |
English |
| LAH314
|
Advertising Annual Certification of Compliance
|
PDF |
English |
| LAH321
|
Credit Insurance Deviation Request Form
|
PDF |
English |
| LAH322
|
Actuarial Certification of Compliance for Indexed-Linked Annuities with an Additional Basis Point Reduction
|
PDF |
English |
| LAH323
|
Life Settlement Provider Data Report
|
PDF |
English |
| LAH345
|
Mandated Benefits and Mandated Offers Reporting Form
|
PDF |
English |
| LAHR324
|
Notice and Consent for HIV-Related Testing
|
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 |
| 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 |
| LAHR344
|
HMO Reconciliation of Benefits to Schedule of Charges
|
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 |
| LHL138
|
Patient Health Plan Coverage
|
PDF |
English |
| LHL139
|
Enrollee's Other Health Plan Coverage
|
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 |
| LHL610
|
Consumer Choice Health Benefit Plans Data Certification
|
PDF |
English |
| NOFR001
|
Prior Authorization of Health Care Services
|
PDF |
English |
| NOFR002
|
Texas Standard Prior Authorization Request Form for Prescription Drug Benefits
|
PDF |
English |
