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