PEO Self-Funded Health Plans

For more information regarding any of the topics below, go to the Company Licensing and Registration home page.

PEO Self-Funded Health Plans
TDI Form Number	Description	File 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 Company Licensing and Registration Fee Transmittal Form to be submitted with filings.	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Statutory Deposit Transaction Form Statutory Deposit Transaction Form is submitted when a securities is deposited or withdrawn.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

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