Financial - Company Licensing and Registration Forms Listing
For more information regarding any of the topics below, go to the Company Licensing and Registration Third Party Administrator home page.
Third Party Administrator - Company Licensing and Registration
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| TDI form number | Description | Format | Language |
|---|---|---|---|
| FIN306 |
Officers and Directors Page Complete Listing of all Current Officers and Directors |
English | |
| FIN321 |
Company Licensing Fee Transmittal Form |
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 | |
| FIN484 |
Administrator Biographical Affidavit TPA form to be completed by each principal (i.e. officer, director, partner, sole proprietor, or owner) |
English | |
| FIN485 |
Service of Process Form for Administrators TPA form required from all foreign or alien applicants, appointing the commissioner of insurance as attorney for service of process. |
English | |
| FIN486 |
Annual Report Form for Administrators TPA Form with required documents to be submitted annually by all Third-Party Administrators holding a certificate of authority under TIC Chapter 4151; due no later than June 30th, with $200 Annual Report filing fee. |
English | |
| FIN487 |
Annual Report for Insurers and HMOs Subject to 28 TAC 7.1605 TPA Form with required documents to be submitted annually by all Insurers and HMOs, subject to 28 TAC 7.1605; due no later than June 30th, with $200 Annual Report filing fee. |
English | |
| FIN488 |
Annual Report Exhibits A-E Form to be submitted with annual report, summarizes business administered in Texas during preceding year |
EXCEL | English |
| FIN489 |
Application for Certificate of Authority Form and instructions for entities wishing to obtain a certificate of authority to do business as an Administrator (TPA) in Texas, under TIC Chapter 4151 |
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 | |
| FIN497 |
Surrender of Third Party Administrator Certificate of Authority Notice of surrendering the COA or Authority for a Third Party Administrator |
English | |
| FIN498 |
Third-Party Administrators Notice of Change of Address and/or Contact form TPA to complete this form notifying the department of a change of address or other contact information |
English | |
| FIN499 |
Checklist for Administrator (TPA) Name Change Checklist to be submitted by a Third-Party Administrator to effect a name change. |
English | |
| FIN502 |
Notice of Change of Control Third-Party Administrator's authorized officer to complete this form for a change of control |
English |
For more information, contact: CompanyLicense@tdi.texas.gov