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Texas Department of Insurance
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PEO Self-Funded Health Plans

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TDI form number Description Format Language
FIN311 Biographical Affidavit
Biographical Affidavit form to be completed by certain officers and directors of insurance companies; compliance with statute
PDF English
FIN321 Company Licensing Fee Transmittal Form
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Statutory Deposit Transaction Form is submitted when a securities is deposited or withdrawn.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
FIN453 Declaration of Trust
Form to be executed for securities held on deposit.
PDF English

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