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Texas Department of Insurance
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Listing of all Texas Department of Insurance forms

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TDI Form Number Description File Format Language
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
AH021 Individual Health Rate / Rate Increase Filing Requirements 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
AS004 Accounting Texas Overhead Assessment
PDF English
CP029 Health Insurance Mediation Request Form
Request health insurance mediation
PDF English
CP029-sp Obtenga ayuda si recibió una factura sorpresa de un proveedor de servicios médicos
PDF Spanish
DWC001 Employer's First Report of Injury or Illness
Rev. 10/05. This form is submitted by the carrier to DWC.
PDF English
DWC001S Employer's First Report of Injury or Illness (for state employees)
Rev. 10/05
PDF English
DWC002 Employer's Report for Reimbursement of Voluntary Payment
Rev. 02/17
PDF English
DWC003 Employer’s wage statement
Rev. 10/22
PDF English
DWC003ME Employee’s multiple employment wage statement
Rev. 05/23
PDF English
DWC003MES Declaración de salario de múltiples trabajos del empleado
Rev. 05/23
PDF Spanish
DWC003S Declaración de salarios del empleador
Rev. 10/22
PDF Spanish
DWC003SD Employer’s wage statement for school districts
Rev. 07/22
PDF English
DWC003SDS Declaración de salario del empleador para distritos escolares
Rev. 07/22
PDF Spanish
DWC004 Employer's Contest of Compensability
Rev. 11/08
PDF English
DWC005 Employer Notice of No Coverage or Termination of Coverage
Rev. 02/18 - For help and an instructional video see “Electronic Filing - Online Forms” page.
PDF English
DWC005 Employer Notice of No Coverage or Termination of Coverage
Rev. 02/18 - static version for mailing and faxing
PDF English
DWC005s Aviso del Empleador de No Cobertura o de Cancelación de la Cobertura
Rev. 02/18
PDF Spanish
DWC006 Supplemental Report of Injury
Rev. 10/05
PDF English
DWC007 Employer’s report of noncovered employee’s work-related injury or illness
Rev. 02/22
PDF English
DWC007S Reporte del empleador para lesiones o enfermedades relacionadas con el trabajo de los empleados sin cobertura
Rev. 02/22
PDF Spanish
DWC008 Return-to-Work Reimbursement Program for Employers
Rev. 04/10
PDF English
DWC020A Correction/Revision/Endorsement to Existing Policy
Rev. 10/05
PDF English
DWC020SI Self-Insured Governmental Entity Coverage Information
Rev. 08/12 - For help and an instructional video see “Electronic Filing - Online Forms” page.
PDF English
DWC022 Request for a required medical examination (RME)
Rev. 06/23
PDF English
DWC022S Solicitud para un examen médico requerido
Rev. 06/23
PDF Chinese
DWC024 Benefit Dispute Agreement
Rev. 11/17
PDF English
DWC024s Acuerdo para Disputa de Beneficios
Rev. 11/17
PDF Spanish
DWC025 Benefit Dispute Settlement
Rev. 11/17
PDF English
DWC025s Acuerdo por Disputa de Beneficios
Rev. 11/17
PDF Spanish
DWC026 Request for Reimbursement of Payment Made by Health Care Insurer
Rev. 01/15
PDF English
DWC027 Designation of insurance carrier’s Austin representative
Rev. 03/22
PDF English
DWC029 Request for standard detailed data reports
Rev. 03/22
PDF English
DWC031 Request to change payment period or purchase an annuity
Rev. 06/23
PDF English
DWC031s Solicitud para cambiar el periodo de pago o para la compra de una anualidad
Rev. 06/23
PDF Spanish
DWC032 Request for designated doctor examination
Rev. 6/23, for use on or after 6/5/2023
PDF English
DWC032S Solicitud para obtener un examen por parte de un médico designado
Rev. 06/23, para usar a partir del 5 de junio de 2023
PDF Spanish
DWC033 Request to reduce income benefits due to contribution
Rev. 05/22
PDF English
DWC041 Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease
Rev. 3/07
PDF English
DWC041 Employee's Claim for Compensation for a Work-Related Injury or Occupational Disease
Rev. 3/07
WORD English
DWC041S Reclamo del Empleado para Compensación por una Lesión Relacionada con el Trabajo o Enfermedad Ocupacional
Rev. 3/07
PDF Spanish
DWC041S Reclamo del Empleado para Compensación por una Lesión Relacionada con el Trabajo o Enfermedad Ocupacional
Rev. 3/07
WORD Spanish
DWC042 Claim for workers’ compensation death benefits
Rev. 12/23
PDF English
DWC042S Reclamación para obtener beneficios de compensación para trabajadores por causa de muerte
Rev. 12/23
PDF Spanish
DWC044 Election to Engage in Arbitration
Rev. 06/12
PDF English
DWC044S Elección para Participar en un Arbitraje
Rev. 05/12
PDF Spanish
DWC045 Request to schedule, reschedule, or cancel a benefit review conference (BRC)
Rev. 07/21
PDF English
DWC045A Request for a Medical Contested Case or SOAH Hearing
Rev. 09/07, applicable only to medical disputes that were filed prior to June 1, 2012
PDF English
DWC045AS Solicitud para una Audiencia para Disputar Beneficios Médicos o Audiencia en la Oficina Estatal de Audiencias Administrativas (SOAH, por sus Siglas en Inglés)
Rev. 10/07, aplicable solamente para las disputas médicas que fueron presentadas antes del 1º de junio del 2012
PDF Spanish
DWC045S Solicitud para programar, reprogramar, o cancelar una conferencia para revisión de beneficios (benefit review conference –BRC, por su nombre y siglas en inglés)
Rev. 07/21
PDF Spanish
DWC045M Request to schedule, reschedule, or cancel a benefit review conference to appeal a medical fee dispute decision (BRC-MFD)
Rev. 07/21
PDF English
DWC045MS Solicitud para programar, reprogramar, o cancelar una conferencia para revisión de beneficios para apelar la decisión de una disputa por honorarios médicos (benefit review conference to appeal a medical fee dispute decision -BRC-MFD, por su nombre y
Rev. 07/21
PDF Spanish
DWC046 Request to accelerate impairment income benefits
Rev. 08/22
PDF English
DWC046S Solicitud para acelerar los beneficios de ingresos de impedimento
Rev. 08/22
PDF Spanish
DWC047 Request to advance benefits
Rev. 08/22
PDF English
DWC047S Solicitud para recibir beneficios por adelantado
Rev. 08/22
PDF Spanish
DWC048 Request to get reimbursed for travel costs
Rev. 07/21
PDF English
DWC048S Solicitud para obtener un reembolso por gastos de viaje
Rev. 07/21
PDF Spanish
DWC049 Request to Schedule a Medical Contested Case Hearing (MCCH)
Rev. 11/17
PDF English
DWC049S Solicitud para Programar una Audiencia para Disputar Beneficios Médicos (Medical Contested Case Hearing –MCCH, por su nombre y siglas en inglés)
Rev. 11/17
PDF Spanish
DWC051 Request for a lump sum payment of impairment income benefits (IIBs)
Rev. 06/23
PDF English
DWC051S Solicitud para recibir un pago en suma total de los beneficios de ingresos de impedimento
Rev. 06/23
PDF Spanish
DWC052 Application for Supplemental Income Benefits
Rev. 02/17
PDF English
DWC052S Aplicación del trabajador para beneficios de ingresos suplementales
Rev. 02/17
PDF Spanish
DWC053 Employee Request to Change Treating Doctor
Rev. 03/12
PDF English
DWC053S Solicitud del Empleado para Cambiar de Médico de Tratamiento
Rev. 03/12
PDF Spanish
DWC054 Notice to Employee: Intention to Request Division Permission to Adjust Benefits
Rev. 02/17
PDF English
DWC054S Aviso al/a la Empleado/a: Intencion de Solicitar permiso a la División para Ajuste de Beneficios
Rev. 02/17
PDF Spanish
DWC055 Request to Adjust Average Weekly Wage for Seasonal Employee
Rev. 02/17
PDF English
DWC055S Solicitud de Ajuste al Salario Medio Semanal de un(a) Empleado/a de Temporada
Rev. 02/17
PDF Spanish
DWC056 Carrier's Request for Seasonal Employee Wage Information from Texas Workforce Commission Records
Rev. 02/17
PDF English
DWC057 Request to extend the date of maximum medical improvement for an approved spinal surgery
Rev. 06/23
PDF English
DWC057S Solicitud para extender la fecha del mejoramiento máximo médico para una cirugía aprobada de la columna vertebral
Rev. 06/23
PDF Spanish
DWC058 Request for Interlocutory Order
Rev. 09/07
PDF English
DWC060 Medical Fee Dispute Resolution Request
Rev. 02/21
PDF English
DWC060S Solicitud para Resolución de Disputas por Honorarios Médicos
Rev. 02/21
PDF Spanish
DWC064 Medical Interlocutory Order Request - Continued Use of a Drug Previously Prescribed and Dispensed and Excluded from TDI-DWC’s Closed Formulary
Rev. 8/11
PDF English
DWC066 Statement of Pharmacy Services
Rev. 12/11
PDF English
DWC067 Designated doctor certification application
Rev. 4/23, for use on or after 4/30/2023
PDF English
DWC068 Designated doctor examination data report
Rev. 6/23, for use on or after 6/5/2023
PDF English
DWC069 Report of Medical Evaluation
Rev. 1/15
PDF English
DWC070 Instructions For Completing The ADA J515 Dental Claim Form For Texas Workers' Compensation Claims
Rev. 10/05
PDF English
DWC072 Medical Quality Review Panel Application
Rev. 01/13
PDF English
DWC073 Work Status Report
Rev. 09/19
PDF English
DWC073s Reporte de Estado de Trabajo
Rev. 09/19
PDF Spanish
DWC074 Description of Injured Employee’s Employment
Rev. 9/09
PDF English
DWC081 Agreement between general contractor and subcontractor to provide workers' compensation insurance
Rev. 10/21
PDF English
DWC081S Acuerdo entre el contratista general y el subcontratista para proporcionar un seguro de compensación para trabajadores
Rev. 10/21
PDF Spanish
DWC082 Agreement between motor carrier and owner operator to provide workers' compensation insurance | Agreement to require owner operator to act as employer
Rev. 02/22
PDF English
DWC082S Acuerdo entre el transportista y el propietario operador para proporcionar un seguro de compensación para trabajadores Acuerdo para requerir que el propietario operador actúe como empleador
Rev. 02/22
PDF Spanish
DWC083 Joint agreement to affirm independent relationship for certain building and construction workers | Agreement to establish employer-employee relationship for certain building and construction workers
Rev. 10/21
PDF English
DWC083S Acuerdo en conjunto para afirmar la relación independiente de ciertos trabajadores de edificación y construcción | Acuerdo para establecer la relación de empleador-empleado para ciertos trabajadores de edificación y construcción
Rev. 10/21
PDF Spanish
DWC084 Exception to application of joint agreement to affirm independent relationship for certain building and construction workers
Rev. 10/21
PDF English
DWC084S Excepción a la aplicación del acuerdo en conjunto para afirmar la relación independiente de ciertos trabajadores de edificación y construcción
Rev. 10/21
PDF Spanish
DWC085 Agreement between general contractor and subcontractor to establish independent relationship
Rev. 10/21
PDF English
DWC085S Acuerdo entre el contratista general y el subcontratista para establecer una relación independiente
Rev. 10/21
PDF Spanish
DWC095 SIF Reimbursement Request Form - Overturned Order or Designated Doctor Opinion
Rev. 01/21
PDF English
DWC096 SIF Reimbursement Request Form – Refund of Death Benefits
Rev. 01/21
PDF English
DWC097 SIF Reimbursement Request Form – Multiple Employment
Rev. 01/21
PDF English
DWC098 SIF Reimbursement Request Form – Pharmaceutical
Rev. 01/21
PDF English
DWC101 Program review report for rejected risk employers
Rev. 11/21
PDF English
DWC101 Program review report for rejected risk employers
Rev. 11/21
WORD English
DWC102 Accident prevention plan cover sheet for rejected risk employer
Rev. 11/21
PDF English
DWC102 Accident prevention plan cover sheet for rejected risk employer
Rev. 11/21
WORD English
DWC104 Employer request for DWC safety consultation
Rev. 11/21
PDF English
DWC104 Employer request for DWC safety consultation
Rev. 11/21
WORD English
DWC105 Accident prevention services worksheet
Rev. 11/21
PDF English
DWC105 Accident prevention services worksheet
Rev. 11/21
WORD English
DWC105 Accident prevention services worksheet
Rev. 11/21
PDF English
DWC105 Accident prevention services worksheet
Rev. 11/21
WORD English
DWC109 Accident prevention services annual report
Rev. 11/21
PDF English
DWC109 Accident prevention services annual report
Rev. 11/21
WORD English
DWC109 Accident prevention services annual report
Rev. 11/21
PDF English
DWC109 Accident prevention services annual report
Rev. 11/21
WORD English
DWC120 Designation of administrative services company administrator
Rev. 03/22
PDF English
DWC121 Claim Administration Contact Information
Rev. 3/20
PDF English
DWC150 Notice of Representation
Rev. 12/16
PDF English
DWC150A Notice of Withdrawal of Representation
Rev. 11/17
PDF English
DWC150AS Aviso de Anulación de Representación Legal
Rev. 11/17
PDF Spanish
DWC150S Aviso de Representación Legal
Rev. 12/16
PDF Spanish
DWC151 Attorney Application for Web Access
Rev. 12/16
PDF English
DWC152 Application for Attorney Fees
Rev. 11/17
PDF English
DWC153 Request for Record Check or Copies of Confidential Claim Information
Rev. 02/21
PDF English
DWC153s Solicitud para Obtener Verificación de Expedientes o Copias de Información Confidencial de la Reclamación
Rev. 02/21
PDF Spanish
DWC154 Workers' Compensation Complaint Form
Rev. 03/16
PDF English
DWC154S Quejas de Compensación para Trabajadores
Rev. 03/16
PDF Spanish
DWC156 Prospective employment authorization and certification
Rev. 08/21
PDF English
DWC156S Certificación y autorización de un posible empleo
Rev. 08/21
PDF Spanish
DWC205 Locations of Employer’s Business(es)
Addendum to DWC Form-005 or DWC Form-020 - Rev. 11/10
PDF English
DWC205S Locaciones del Negocio(s) del Empleador
Suplemento para el Formulario DWC005 o Formulario DWC020 - Rev. 11/10
PDF Spanish
EDI-02 Insurance carrier or trading partner medical electronic data interchange (EDI) profile
Rev. 04/22
PDF English
EDI-03 Claim and medical EDI compliance coordinator and medical EDI trading partner notification
Rev. 02/22
PDF English
FIN111 Health Entities Checklist
Filing requirements
PDF English
FIN116 HMO Supplement - Annual Information
PDF English
FIN117 TDI Instructions for Filing CPA Audited Financial Reports
PDF English
FIN119 Life, Accident and Health Insurers
Filing requirements
PDF English
FIN122 Property & Casualty Insurers Filing Requirements Checklist
Filing requirements
PDF English
FIN123 TDI Supplement Form for County Mutuals
PDF English
FIN127 Title Checklist
Filing requirements
PDF English
FIN128 Annual Statement Blank - Farm Mutual Companies
EXCEL English
FIN128 Annual Statement Blank - Farm Mutual Companies
PDF English
FIN138 Texas Supplemental A for County Mutuals Form
Texas Supplemental "A" for County Mutuals Form
PDF English
FIN139 Annual Operations Report
Form FIN139 required to be filed annually by premium finance company, due April 1. Rev. 3/2021
PDF English
FIN145 Notice of intent to relocate books and records outside of Texas
Form TDI BR-93
PDF English
FIN150 Texas Negotiated Deductible Workers' Compensation Form
PDF English
FIN160, PF1 Application for An Insurance Premium Finance Company License (Form PF1)
Premium Finance application for initial license to operate in Texas
PDF English
FIN161, PF1A Supplemental Application for a Premium Finance Company (Form PF1A)
Form premium finance company completes to notify TDI of changes, such as an additional location, relocation, name change and/or ownership change
PDF English
FIN162, PF1B Application for an Insurance Premium Finance License by a Bank or Savings and Loan Association (Form PF1B)
Application for a bank or savings and loan to be a licensed premium finance company
PDF English
FIN164, PF2 Premium Finance List of Principals
List all officers, directors and contact persons of Premium Finance Company
PDF English
FIN165, PF3 Questionnaire - Premium Finance Applicant (Form PF3)
Questionnaire to be completed by those wishing to obtain a premium finance company license
PDF English
FIN166, PF4 Biographical Affidavit - Premium Finance Applicant (Form PF4)
Form to be completed by each individual named on Form PF2.
PDF English
FIN167, PF5 List of Other States of Licensure - Premium Finance Applicant (Form PF5)
List of other states where Premium Finance Company is licensed
PDF English
FIN168, PF6 Appointment of Statutory Agent and Consent to Service - Premium Finance Applicant (Form PF6)
Form to be completed by premium finance company, appointing statutory agent for service of process who resides in the state of Texas
PDF English
FIN169, PF7 Premium Finance Premium Comparison Disclosure Form
Disclosure form/notice regarding interest charges incurred when purchasing liability insurance through the Texas Automobile Insurance Plan Association (TAIPA), if paid through a monthly installment plan.
PDF English / Spanish
FIN170, PF Schedule A Filings Required for Premium Finance Application for Additional Location (Schedule A)
Checklist outlining the documents required when Premium Finance Company is adding a location
PDF English
FIN171, PF Schedule B Filings Required for Premium Finance Application for Relocation (Schedule B)
Checklist outlining documents required when a Premium Finance Company is relocating
PDF English
FIN172, PF Schedule C Filings Required for Premium Finance Application for Name Change (Schedule C)
Checklist outlining documents required for a Premium Finance Company to change its name
PDF English
FIN173, PF Schedule D Filings Required for Premium Finance Application for Change of Ownership (Schedule D)
Checklist outlining requirements for Premium Finance Company to change ownership
PDF English
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
PDF English
FIN181 Biographical Affidavit for Captive Insurance Company
Biographical Affidavit form for individuals that oversee management of the Captive Insurance Company
PDF 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
PDF 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
PDF 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
PDF English
FIN187 Uniform Checklist for Reciprocal Jurisdiction Reinsurers
PDF English
FIN188 Application checklist for Certified Reinsurers
PDF English
FIN189 Certificate of Accredited Assuming Insurer (AR-1)
PDF English
FIN190 CR-1 Certificate of Certified Reinsurer
PDF 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)
PDF English
FIN194 Annuity Transaction Disclosure form
PDF English
FIN195 Consumer Refusal to Provide Information Before Buying an Annuity form
PDF English
FIN196 Consumer Disclosure When Buying an Annuity Not Recommended by an Agent
PDF English
FIN197 Application Checklist for Accredited or Trusteed Assuming Insurer
PDF English
FIN202 Texas Policyholder Dividend Disbursement Notification/Application
FIN 202 Texas Policyholder Dividend Disbursement Notification Application
PDF English
FIN244 CPA Audited Financial Report - Intent Form
Register a CPA to file an audited financial report
PDF English
FIN246 Affidavit for Exemption from Filing CPA Audited Financial Report
CPA Exemption Form
PDF English
FIN251 Annual Statement Blank - Mutual Assessments, Burials, LMAs
EXCEL English
FIN251 Annual Statement Blank - Mutual Assessments, Burials, LMAs
PDF English
FIN252 HMO Quarterly Supplement
PDF English
FIN300 Company Name Application
Application to reserve a company name
PDF English
FIN302 HMO Application for Certificate of Authority
Application for an HMO to do business in the state of Texas
PDF English
FIN306 Officers and Directors Page
Complete Listing of all Current Officers and Directors
PDF English
FIN307 Attorney-in-Fact and Underwriters Page
Lists the Attorney-in-Fact and Underwriters of Lloyds and Reciprocals
PDF English
FIN310 Application For A License As An Advisory Organization
Submit application to be licensed as an Advisory Organization
PDF English
FIN311 Biographical Affidavit
Biographical Affidavit form to be completed by certain officers and directors of insurance companies; compliance with statute
PDF English
FIN312 Attorney for Service form
Attorney for Service form
PDF English
FIN321 Company Licensing Fee Transmittal Form
Company Licensing and Registration Fee Transmittal Form to be submitted with filings.
PDF English
FIN324 Biographical Affidavit Update
submitted as notification of changes to biographical affidavit
PDF 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
PDF 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
PDF 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
PDF 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
PDF 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
PDF 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
PDF 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
PDF English
FIN351 Voluntary Dissolution Checklist
Instructions for a Texas-Domestic Company wanting to Dissolve and Cancel its Certificate of Authority
PDF English
FIN353 Biographical Affidavit and Fingerprint Requirements for Texas-Domestic Insurers
Requirements and instructions for submitting biographical affidavits and fingerprints for Texas-domestic insurers
PDF English
FIN354 Biographical Affidavit and Fingerprint Requirements for Foreign Insurers
Instructions and requirements for submitting biographical affidavit and fingerprints for foreign insurers
PDF 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)
PDF 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
PDF English
FIN358 HMO DBA Filing Checklist
Filing instructions relating to an HMO's DBA, Assumed Name, Trade Mark, Service Marks and Logos
PDF English
FIN359 HMO Home Office Change Checklist
Filing instruction related to a Health Maintenance Organization's subsequent filing for a home office change
PDF English
FIN360 HMO Name Change Checklist
Instructions related to a Health Maintenance Organization's subsequent filing for a name change
PDF English
FIN361 HMO Service Area Expansion
Filing instructions for a Health Maintenance Organization wishing to provide HMO coverage in additional counties
PDF English
FIN363 HMO Merger Checklist
Checklist and instructions for a Health Maintenance Organization's merger filing
PDF 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.
PDF 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.
PDF English
FIN367 Application for Reciprocal or Inter-Insurance Exchanges
Application to transact business as a reciprocal or inter-insurance exchange
PDF English
FIN368 Instructions for the Original Incorporation of Texas Lloyds Company
Instructions for the original incorporation of a Lloyds Company
PDF 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
PDF 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
PDF English
FIN371 Checklist for Change in Attorney in Fact for Reciprocals
Attorney-in-fact Change Checklist for Reciprocals (only)
PDF 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
PDF 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)
PDF English
FIN374 MEWA Application to Do Business
Application form to do business as a Multiple Employer Welfare Arrangement (MEWA)
PDF English
FIN375 Application for Initial Certificate of Authority (MEWA)
Multiple Employer Welfare Arrangement (MEWA) application for a temporary, or initial certificate of authority
PDF English
FIN376 MEWA Officers, Directors, and Trustees Page
Listing of all officers, directors, and trustees associated with the Multiple Employer Welfare Arrangement (MEWA)
PDF English
FIN377 Service of Process (MEWA)
Multiple Employer Welfare Arrangement (MEWA) Service of Process form
PDF English
FIN378 MEWA Annual Filing Checklist
Instructions for submitting annual filing for a Multiple Employer Welfare Arrangement (MEWA)
PDF 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
PDF 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 Form #1
PDF English
FIN383 CCRC 2 - Continuing care provider
CCRC 2 - Application for Approval by the Commissioner for Release of Loan Reserve Fund Escrow Account Amounts
PDF English
FIN384 CCRC 3 - Officers and Directors Page
Continuing Care Retirement Community (CCRC) listing of all associated officers and directors, CCRC Form #3
PDF 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
PDF 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
PDF 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
PDF 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
PDF English
FIN390 CCRC 7 - Change of Control Statement
PDF 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
PDF 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
PDF 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
PDF English
FIN394 CCRC 11 - Notice by Provider of Repayment of Previously Released Funds to Escrow Account
PDF English
FIN395 CCRC 12 - Affidavit of Repayment of Previously Released Funds to the Reserve Fund Escrow Account
PDF English
FIN396 CCRC 13 - Notice of Lien
PDF English
FIN397 CCRC 14 - Calculations Concerning Conditions
PDF English
FIN398 CCRC Name Change Checklist
Continuing Care Retirement Community (CCRC) charter amendment checklist to effect a name change
PDF English
FIN403 CCRC Release Escrow Checklist
PDF English
FIN404 Workers Compensation Group Self-Insurance Coverage Acknowledgement of Indemnity Agreement
Workers' Compensation Self-Insurance Group (SIG) coverage acknowledgement of indemnity agreement; employer's joint and several liability agreement
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
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
PDF 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
PDF 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.
PDF 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.
PDF 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.
PDF 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.
PDF 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.
PDF English
FIN430 License Application for a Life Settlement Provider or Broker
Original application for licensure of a life settlement broker or provider, which includes checklists for filing requirements of the initial application
PDF English
FIN431 Application for Renewal, Surrender, or Change of Information for a Life Settlement Provider or Broker
Application for renewal of a broker or provider license or to report change of information of an existing life settlement broker or provider
PDF English
FIN432 Life Agent Notification to TDI to act as a Life Settlement Broker
Required for applicants who have held a resident Texas life or life and health license for at least one year
PDF English
FIN434 Biographical Affidavit for Life Settlement Providers or Brokers
Biographical affidavit. Must be completed by all individuals specified in the instructions of FIN430 and FIN431, as adopted by rule.
PDF English
FIN435 Checklist for Placing an Initial Statutory Deposit
Checklist for an insurance company to initially place security funds on deposit.
PDF 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.
PDF English
FIN437 Checklist for Substituting Securities on Deposit
Checklist outlining documents required for an insurance company to substitute securities held on deposit.
PDF 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.
PDF English
FIN450 Joint Control Agreement for Lloyds
Form to be executed by Lloyds plan when placing required net assets as required by statute
PDF English
FIN453 Declaration of Trust
Form to be executed for securities held on deposit.
PDF English
FIN454 Checklist for Custodian Change for Securities on Deposit
PDF English
FIN455 Checklist for Renewing a Certificate of Deposit
PDF English
FIN464 Workers' Compensation Self-Insured Group (SIG) Administrator or Service Company Bond
Format Instructions
PDF English
FIN465 Workers Compensation Self-Insurance Group Application
Application for Certificate of Approval to Conduct Workers Compensation Self-Insurance Group (SIG) Business
PDF English
FIN466 Workers Compensation Self-Insurance Group (SIG) Application Checklist
Application checklist for workers compensation Self-Insurance Groups (SIG)
PDF English
FIN467 Workers Compensation Self-Insurance Group (SIG) Employer Membership Form
Employer membership form for workers compensation Self-Insurance Groups
PDF English
FIN468 Workers Compensation Self-Insurance Group (SIG) Notification Form
Mandatory notification to the commissioner of insurance regarding any one of a variety of possible changes that a workers compensation Self-Insurance Group (SIG) makes
PDF English
FIN469 Workers Compensation Self-Insurance Group (SIG) Termination of Certificate of Approval Checklist
Checklist for a workers compensation Self-Insurance Group (SIG) to apply for termination of its certificate of approval
PDF English
FIN470 Workers Compensation Self-Insurance Group (SIG) Merger Checklist
Checklist for a workers compensation Self-Insurance Group (SIG) to merge with another SIG engaged in the same or similar type of business
PDF English
FIN471 Workers Compensation Self-Insurance Group (SIG) 5% Investments
Instruction for a workers compensation Self-Insurance Group (SIG) regarding authorized investments for meeting minimum capital and surplus and reserves
PDF English
FIN472 Workers Compensation Self-Insurance Group (SIG) Hazardous Financial Condition Notice
Instructions and checklist for a workers compensation Self-Insurance Group (SIG) should it become insolvent or discover a hazardous financial condition
PDF English
FIN473 Workers Compensation Self-Insurance Group (SIG) Changes to Service Company Agreements Checklist
Checklist for a workers compensation Self-Insurance Group (SIG) if there are any changes to agreements or new agreements are entered into with an administrator/service company
PDF English
FIN474 Workers Compensation Self-Insurance Group (SIG) Change in Security for Incurred Liabilities Form
Security deposit instructions for a workers compensation Self-Insurance Group (SIG)
PDF English
FIN475 Workers Compensation Self-Insurance Group (SIG) Change in Performance or Fidelity Bond Checklist
Checklist for a workers compensation Self-Insurance Group (SIG) for a change in performance or fidelity bond
PDF English
FIN476 Workers Compensation Self Insurance Group Changes to Corporate Governance Documents Checklist
Checklist for a workers compensation Self Insurance Group to make a change to its corporate governance documents, including By Laws, Articles of Association, Incorporation, or other documentation used to verify the existence of the SIG and or Trust
PDF English
FIN477 Workers Compensation Self-Insurance Group (SIG) Excess Insurance Checklist
Checklist for a workers compensation Self-Insurance Group (SIG) to establish excess insurance for losses
PDF English
FIN478 Workers Compensation Self-Insurance Group (SIG) Financial Pro Forma
Financial Pro Forma for a workers compensation Self-Insurance Group (SIG)
PDF English
FIN479 Workers Compensation Self-Insurance Group (SIG) Movement of Books and Records Checklist
Checklist for a workers compensation Self-Insurance Group (SIG) to request to move its books and records out of Texas
PDF English
FIN480 Workers Compensation Self-Insurance Group (SIG) Increase or Decrease in Membership Checklist
Checklist for a workers compensation Self-Insurance Group (SIG) if there is an increase or decrease in membership
PDF 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)
PDF English
FIN483 Transactions Cash Receipts Transmittal Form
PDF English
FIN484 Administrator Biographical Affidavit
TPA form to be completed by each principal (i.e. officer, director, partner, sole proprietor, or owner)
PDF 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.
PDF 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.
PDF 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.
PDF 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
PDF 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.
PDF English
FIN491 Health Care Collaborative (HCC) Acquisition Form
Department notification of an acquisition of a Health Care Collaborative
PDF English
FIN492 Application for Certificate of Authority to do the business of a Health Care Collaborative in the state of Texas
Health Care Collaborative application for initial or renewal of certificate of authority
PDF English
FIN493 Health Care Collaboratives Officers and Directors Page
Health Care Collaborative Officer and Director Information
PDF English
FIN494 Health Care Collaborative Payor Information Form
Form used to provide HCC market power information
PDF English
FIN495 Request to Convert to Renewal of Certificate of Authority (to do the business of a Health Care Collaborative)
Used to request that the Department convert an examination to an early renewal application
PDF English
FIN496 Transmittal Checklist for Health Care Collaborative (HCC) Filings
Health Care Collaborative Filing Transmittal Checklist
PDF English
FIN497 Surrender of Third Party Administrator Certificate of Authority
Notice of surrendering the COA or Authority for a Third Party Administrator
PDF 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
PDF English
FIN499 Checklist for Administrator (TPA) Name Change
Checklist to be submitted by a Third-Party Administrator to effect a name change.
PDF English
FIN501 Appointment Cancel for Cause
Use this form to submit notification of appointment cancellation for cause. All other appointment transactions must be completed electronically using National Insurance Producer Registry or Sircon.
PDF English
FIN502 Notice of Change of Control
Third-Party Administrator's authorized officer to complete this form for a change of control
PDF English
FIN505 Licensing Corporate Insurance Agents Bond (aka Insurance Agency Bond)
Method of showing proof of financial responsibility to obtain corporate license
PDF English
FIN507 Application for insurance agency license
Use for county mutual, risk manager, funeral pre-arrangement life, life and health insurance counselor, and life insurance not exceeding $25,000. For other license types, apply online at www.Sircon.com.
PDF English
FIN509 Public Insurance Adjuster Bond - Licensing
Certifies that the persons listed on the form are bound to the Texas Department of Insurance in the sum of $10,000 as specified at 28 Texas Administrative Code Section 19.705.
PDF English
FIN510 Licensing Application for Reinsurance Intermediary License
For individuals and entities to apply for a Reinsurance Intermediary License under the provisions of TIC, Chapter 4152.
PDF English
FIN511 Licensing Reinsurance Intermediary Biographical Affidavit
To register individuals to be associated to a Reinsurance Intermediary License.
PDF English
FIN512 Licensing Reinsurance Intermediary Agent For Service of Process
Nonresident Reinsurance Intermediary License applicant or licensee must use this form to appoint a Texas resident on whom a notice or order or process may be served.
PDF English
FIN513 Licensing Reinsurance Intermediary Bond
Method of showing proof of financial responsibility for a Reinsurance intermediary License.
PDF English
FIN514 Specialty Insurance License Application
Specialty Insurance License Application (fka Li004,LHL207)
PDF English
FIN517 CE Exemption or Extension
Application for licensee CE Exemption or Extension. Revised 07/2020
PDF English
FIN519 CE Automatic Fines Transmittal
Continuing Education Fines. Revised 07/2020
PDF English
FIN520 CE provider information update
PDF English
FIN521 Provider Audit Affidavit
Used only by continuing education providers. Revised 01/2019
PDF English
FIN522 Licensee Request for Qualifying Credit
TEXAS Qualifying Continuing Education Credit (fka LHL615). Revised 07/2020
PDF English
FIN523 Request for Association Credit Accepted by TDI
Request for Association Credit (fka LHL617). Revised 01/2019
PDF English
FIN524 Discount Health Care Program Operator Marketers Form
Use this form to provide a list of the marketers authorized to sell or distribute the program operator's program under the program operator's name, and a list of the marketing entities authorized to private label the program operator's programs.
EXCEL English
FIN525 Discount Health Care Program Operator Surety Bond Form
Use this form of an original surety bond in the principal amount of $50,000 to show Financial Responsibility. Rev. 01/2019
PDF English
FIN526 Discount Health Care Program Operator Biographical Certificate Form
Discount Health Care Program Operator Biographical Certificates. Follow the instructions within the form for completion. Rev 01/2019
PDF English
FIN527 Discount Health Care Program Operator Registration Form
Form for Registration as a Discount Health Care Program Operator. Rev. 01/2019
PDF English
FIN528 Entity Name Change/ Assumed Name (DBA) Request
Use this form to update an official entity name change or register an assumed name (DBA) with TDI.
PDF English
FIN529 Life Agent License Use Affidavit
Request CE waiver for life insurance not exceeding $25,000 agent licenses.
PDF English
FIN530 Voluntary Surrender of Texas Insurance License
PDF English
FIN531 Biographical Form and Certification of License Qualification Following a Change of Control
Use this form to report changes to control of a licensed insurance agency; or to report new individuals to be associated with or disassociated from a currently licensed insurance agency.
PDF English
FIN533 Agent / Adjuster name or address change request form
PDF English
FIN535 Public Insurance Adjuster Contract
This contract form is prescribed by the Texas Department of Insurance to satisfy contract requirements for Public Insurance Adjusters effective January 01, 2014.
PDF English
FIN540 Agency address change request form
PDF English
FIN548 Captive Management Company Biographical Certificate Form
Form used for Captive Management Company's Biographical Certificate information. Follow the instructions within the form.
PDF English
FIN549 Captive Management Company Registration Form
Form used for Captive Management Company Registration information. Follow the instructions within the form.
PDF English
FIN584 Form D Application - Prior Notice of Transaction
PDF English
FIN585 Service Agreement Checklist
Management, Service, Cost Sharing, Tax Allocation, Rental, Lease Agreement Checklist
PDF English
FIN586 MGA Contract Review Checklist
Managing General Agency Contract Review Checklist
PDF English
FIN587 TPA Contract Review Checklist
Third Party Administrator Contract Review Checklist
PDF English
FIN588 Custodial Agreement Review Checklist
PDF English
FIN590 Financial Analysis Fee Transmittal Form
for MEWAs and CCRCs
PDF English
FIN594 Application for Residency Change to Texas
PDF English
FIN599 Cybersecurity Checklist
PDF English
FIN604 Application for authority to offer continuing care in residence in Texas under Health and Safety Code Section 246.0025(b).
CCRC Form 1a
PDF 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
PDF English
FIN609 Annual Verification of Fidelity Bond Coverage (HMO Employee)
PDF English
FIN610 Annual Verification of Fidelity Bond Coverage (management contractor employees)
PDF English
FIN611 RFQ Application – Claims Services
PDF English
FIN612 RFQ Application – Information Technology Services
PDF English
FIN613 RFQ Application – Legal Services
PDF English
FIN614 RFQ Application – Reinsurance Services
PDF English
FIN615 RFQ Application – Special Deputy Receiver
PDF English
FIN616 RFQ Application – Accounting Services
PDF English
FIN700 Appointment certification
PDF English
FIN-NA CE Example Course Evaluation
Sample Only
PDF English
FINT01 Escrow Officer Name/Address Change Request
PDF English
FINT03 Title insurance agent or direct operation renewal application
Renew online at Sircon and follow the TDI tutorials before starting the renewal process.
PDF English
FINT05 CE Exemption/Extension Request
PDF English
FINT08 Title insurance licensing biographical information
PDF English
FINT09 Escrow officer appointment
PDF English
FINT10 Title insurance agent or direct operation appointment
PDF English
FINT22 Title licensee: continuing education credit request
PDF English
FINT120 Abstract Plant Information
Title Agency Abstract Plant Information
PDF English
FINT122 Title Insurance Agent/Direct Operation Bond
PDF English
FINT123 Escrow Officers Schedule Bond
PDF English
FINT129 Title insurance agent or direct operation change request form
Used for Title Agency information updates
PDF English
FINT143 Application for title insurance agent or direct operation license
Apply online at www.Sircon.com and follow tutorials provided on TDI website for fastest processing.
PDF English
FR028 Suspected Insurance Fraud Report (SIU) Form
PDF English
FR029 Suspected Insurance Fraud Reporting form for Consumers
PDF English
FR029 Suspected Insurance Fraud Reporting form for Consumers (Spanish)
PDF Spanish
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
HR197 Acknowledgement of Mandatory Training
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
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 Checklist and Certification 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
LHL005 URA Application Form
Application to apply for URA Certification, renew a URA Certification or update a URA Certification.
PDF English
LHL006 IRO Application
Application to apply for IRO Certification, renew an IRO Certification or update an IRO Certification
PDF English
LHL007 Supplemental Certification for IRO Renewal
Attach this form to the renewal application. You can attach it in the online renewal form or with the IRO Application, Form LHL006.
PDF English
LHL009 Request for Review by an IRO
Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity
PDF English
LHL009 Spanish Solicitud para una revisión por parte de una Organización de Revisión Independiente
[En Español] - Solicitud para pedir una revisión por parte de una Organización de Revisión Independiente (Independent Review Organization- IRO por su nombre y siglas en inglés) para las disputas médicas necesarias de pacientes, empleados lesionados, representantes del paciente o proveedores de atención médica.
PDF Spanish
LHL011 Notice of Rescission of Preauthorization Exemption and Right to Request an Independent Review
PDF English
LHL050 Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or after June 1, 2010
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
LHL234 Application Package
PDF English
LHL234a Other Professional Degrees
Attachment A
PDF English
LHL234b Other Post-Graduate Education
Attachment B
PDF English
LHL234c Other Work History
Attachment C
PDF English
LHL234d Other Current Hospital Affiliations
Attachment D
PDF English
LHL234e Other Previous Hospital Affiliations
Attachment E
PDF English
LHL234f Other Practice Locations
Attachment F
PDF English
LHL234g Malpractice Claims History
Attachment G
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
LHL658 Application for Approval Exclusive Provider Benefit Plan (EPO) and Preferred Provider Benefit Plan (PPO)
PDF English
LHL705 Workers’ Compensation Health Care Network Application
PDF English
LHL707 HMO Network Access Plan Requirements
PDF English
LHL708 Workers' Compensation Network Access Plan Checklist
WC Network Access Plan Checklist
PDF English
LHL709 Certification of Independence and Qualifications of the Reviewer
PDF English
LHL710 Holder of Bonds or Notes Over $100,000
PDF English
LHL711 Addendum to Biographical Affidavit
PDF English
LHL712 IRO Notice of Decision Template - HC
WORD English
LHL713 IRO Notice of Decision Template - WC
WORD English
LHL715 Provider Network Contracting Entity Registration and Exemption of Affiliates Form
PNCE Registration and Exemption Form
PDF English
LHL716 Health Maintenance Organization Annual Network Adequacy Report and Access Plan Checklist
PDF English
LHL717 Utilization Review Agent's (URA) Designated Contact for IRO Requests
PDF English
LHL718 Health Maintenance Organization (HMO) Physician / Provider Contract Requirements
Used as guide to indicate the mandatory provisions and benefits required in a Provider Contract
PDF English
LHL719 HMO Delegation Agreement Checklist
PDF English
LHL720 Workers' Compensation Health Care Network Provider Contract Checklist
PDF English
LHL721 Workers’ Compensation Network Contract with Insurance Carrier Contract Requirements Checklist
PDF English
LHL722 Workers' Compensation Health Care Network Management Contract Checklist
PDF English
MentorApp Historically Underutilized Business
WORD English
New Employee Notice Vietnamese New Employee Notice
covered and non-covered employers shall notify their employees of coverage status, in writing
PDF Vietnamese
New Employee Notice English New Employee Notice
covered and non-covered employers shall notify their employees of coverage status, in writing
PDF English
New Employee Notice Spanish New Employee Notice
Covered and non-covered employers shall notify their employees of coverage status in writing.
PDF Spanish
NOFR001 Prior Authorization of Health Care Services
PDF English
NOFR002 Texas Standard Prior Authorization Request Form for Prescription Drug Benefits
PDF English
Notice 5 English Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF English
Notice 5 Spanish Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Spanish
Notice 5 Vietnamese Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Vietnamese
Notice 6 English Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF English
Notice 6 Spanish Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Spanish
Notice 6 Vietnamese Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Vietnamese
Notice 7 English Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF English
Notice 7 Spanish Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Spanish
Notice 7 Vietnamese Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Vietnamese
Notice 8 English Required Workers’ Compensation Coverage
(building or construction projects for governmental entities)
PDF English
Notice 8 Spanish Required Workers’ Compensation Coverage
(building or construction projects for governmental entities)
PDF Spanish
Notice 9 English Notice Regarding Certain Work-Related Communicable Diseases and Eligibility for Workers' Compensation Benefits
(law enforcement officers, fire fighters, emergency medical service employees, paramedics, and correctional officers)
PDF English
Notice 9 Spanish Notice Regarding Certain Work-Related Communicable Diseases and Eligibility for Workers' Compensation Benefits
(law enforcement officers, fire fighters, emergency medical service employees, paramedics, and correctional officers)
PDF Spanish
Notice 10 English Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF English
Notice 10 Spanish Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Spanish
Notice 10 Vietnamese Notice to Employees Concerning Workers' Compensation in Texas
must be posted for employees to read
PDF Vietnamese
PC068 Impact-Resistant Roofing Installation Form
Roofing Installation Information and Certification for Reduction in Residential Insurance Premiums.
PDF English
PC321 Amusement Ride Certificate of Inspection / Reinspection
(Form AR-100)
PDF English
PC322 Texas Amusement Ride Safety Inspection and Insurance Act Daily Inspection Record
(Form AR-300)
PDF English
PC323 Amusement Ride Schedule of Operations in Texas
(Form AR-102)
PDF English
PC324 Quarterly Injury Report Amusement Ride Safety Inspection and Insurance Act
(Form AR-800)
PDF English
PC325 Quarterly Governmental Action Report Amusement Ride Safety Inspection and Insurance Act
(Form AR-801)
PDF English
PC326 Certificate of Mold Damage Remediation
Inspectors have to be licensed by the Texas Department of License and Regulation in order complete this form.
PDF English
PC327 Certificate of Appliance-Related Water Damage Remediation
PDF English
PC328 (CD-1) Use of Credit Information Disclosure
PDF English
PC328 (CD-1) Divulgación del Uso de la Información de Crédito
PDF Spanish
PC340 Certification of Sections 2251.251 - 2251.252
Exemption Compliance (EC-1)
PDF English
PC350 (WPI-1) Application for Windstorm Inspection Certificate of Compliance
PDF English
PC357 VIP Application for Residential Property Inspector License/Certificate
PDF English
PC358 P&C Filing Transmittal Form
PDF English
PC360 Company Certification
Mortgage Guaranty Rate Filings
PDF English
PC361 Credit Scoring Model Filing Form
PDF English
PC365 Exhibit C
Statewide Average Rate Level Information
PDF English
PC366 Exhibit D
Historical Experience
PDF English
PC367 Exhibit E
Expense Information - Including Disallowed Expense Adjustment
PDF English
PC368 Exhibit F
Expense Information - For Workers' Compensation and Mortgage Guaranty
PDF English
PC369 Exhibit G
Loss Costs Reference Information
PDF English
PC370 Exhibit H
Multi-Peril Rate Reference Information
PDF English
PC371 Exhibit L
Profit Provision Information
PDF English
PC372 Certificate of Insurability (VIP1)
PDF English
PC373 Residential Property Condition Evaluation Report (VIP2)
PDF English
PC374 Territory Exhibit
Display of Counties Affected by 15% Territory Rule
PDF English
PC375 CS Exhibit
Support for use of Credit Scoring
PDF English
PC376 Exhibit WC
Workers' Compensation
PDF English
PC377 Territory Exhibit
Support for Territorial Deviations
PDF English
PC381 Public Information Notice for Amusement Rides
PDF English
PC382 (WPI-2-BC-6) Inspection Verification
For projects that began construction between January 1, 2017, and August 31, 2020
PDF English
PC390 Loss Control Representative Qualification Review
PDF English
PC391 Field Safety Representative with a Specialty in Hospitals Qualification Review
PDF English
PC400 Contact Information Update Request
To be completed by Appointed Qualified Inspectors only
PDF English
PC404 Compliance Questionnaire - Use of Credit Information
WORD English
PC404 Compliance Questionnaire - Use of Credit Information
PDF English
PC405 CM Exhibit
Additional Information for Certain County Mutuals
PDF English
PC406 Appraisal Umpire Roster Application
PDF English
PC407 Mediator Roster Application
PDF English
PC410 2018 TTIGA Guaranty Assessment Recoupment Charge Remittance Form
(Effective January 1 - December 31, 2018)
PDF English
PC411 Title Agent's Unencumbered Assets Certification (Form T-S1)
PDF English
PC412 Tripartite Agreement (Form T-S2)
PDF English
PC413 Solvency Account Release Request (Form T-S3)
PDF English
PC414 Annual Report of Title Company's Officers Authorized to Provide Information on Agent Financial Matters (Form T-S4)
PDF English
PC415 Financial Matter Disclosure Report (Form T-S4-A)
PDF English
PC416 Title Agent Certification of Agent's Quarterly Tax Reports (Form T-S5)
PDF English
PC417 Texas Title Insurance Agent's Minimum Capitalization Bond
PDF English
PC418 Prescribed Auto ID Card Form (28 TAC §5.204)
PDF English
PC419 Certificate of Insurance Filing Transmittal Form
PDF English
PC420 Exhibit A
Rate Filing Checklist
PDF English
PC421 Exhibit B
SERFF Rate Data
PDF English
PC422 County Exhibit
Average Premium Change by County
PDF English
PC423 VIP Renewal for Residential Property Inspector License/Certificate
PDF English
PC424 Form usage table — short version (up to 90 forms)
Optional/Mandatory/Conditional Mandatory
PDF English
PC425 (AQI-1) Application for Appointment as a Qualified Inspector
PDF English
PC426 (AQI-R) Application Renewal for Appointment as a Qualified Inspector
PDF English
PC427 Form usage table — long version (up to 470 forms)
Optional/Mandatory/Conditional Mandatory
PDF English
PC428 (WPI-2-BC-5) Inspection Verification
For ongoing improvements for construction that began between January 1, 2008, and December 31, 2016.
PDF English
PC434 (WPI-2E) Application for Certificate of Compliance
For completed improvements.
PDF English
PC436 (WPI-2-BC-7) Inspection Verification
For ongoing improvements for construction that began on or after April 1, 2020 (2018 building code).
PDF English
PLN01 Notice of Denial of Compensability/Liability and Refusal to Pay Benefits
Rev. 07/21
WORD English
PLN01S Notice of Denial of Compensability/Liability and Refusal to Pay Benefits
Rev. 07/21
WORD Spanish
PLN02A Notice of First Temporary Income Benefit Payment
Rev. 07/21
WORD English
PLN02AS Notice of First Temporary Income Benefit Payment
Rev. 07/21
WORD Spanish
PLN02B Notice of first payment of income benefits on an acquired claim
Rev. 07/23
WORD English
PLN02BS Notice of first payment of income benefits on an acquired claim
Rev. 07/23
WORD Spanish
PLN03A Notice of Maximum Medical Improvement and No Permanent Impairment
Rev. 07/21
WORD English
PLN03AS Notice of Maximum Medical Improvement and No Permanent Impairment
Rev. 07/21
WORD Spanish
PLN03B Notice of Maximum Medical Improvement and Permanent Impairment
Rev. 07/21
WORD English
PLN03BS Notice of Maximum Medical Improvement and Permanent Impairment
Rev. 07/21
WORD Spanish
PLN03C Notice of Maximum Medical Improvement and Estimated Permanent Impairment
Rev. 07/21
WORD English
PLN03CS Notice of Maximum Medical Improvement and Estimated Permanent Impairment
Rev. 07/21
WORD Spanish
PLN04 Notice of Eligibility for Lifetime Income Benefits
Rev. 07/21
WORD English
PLN04S Notice of Eligibility for Lifetime Income Benefits
Rev. 07/21
WORD Spanish
PLN05 Notice of First Death Benefit Payment
Rev. 07/21
WORD English
PLN05S Notice of First Death Benefit Payment
Rev. 07/21
WORD Spanish
PLN06 Notice of Employer Full Salary Payment
Rev. 07/21
WORD English
PLN06S Notice of Employer Full Salary Payment
Rev. 07/21
WORD Spanish
PLN07 Notice of Change of Indemnity Benefit Type
Rev. 07/21
WORD English
PLN07S Notice of Change of Indemnity Benefit Type
Rev. 07/21
WORD Spanish
PLN08 Notice of Change in Amount of Indemnity Benefit Payment
Rev. 07/23
WORD English
PLN08S Notice of Change in Amount of Indemnity Benefit Payment
Rev. 07/23
WORD Spanish
PLN09 Notice of Suspension of Indemnity Benefits
Rev. 07/21
WORD English
PLN09S Notice of Suspension of Indemnity Benefits
Rev. 07/21
WORD Spanish
PLN10A Notice of reinstatement of indemnity benefits
Rev. 07/23
WORD English
PLN10AS Notice of reinstatement of indemnity benefits
Rev. 07/23
WORD Spanish
PLN10B Notice of lump sum payment of income or death benefits
Rev. 07/23
WORD English
PLN10BS Notice of lump sum payment of income or death benefits
Rev. 07/23
WORD Spanish
PLN11 Notice of Disputed Issues and Refusal to Pay Benefits
Rev. 07/23
WORD English
PLN11S Notice of Disputed Issues and Refusal to Pay Benefits
Rev. 07/23
WORD Spanish
PLN12 Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 12/23
WORD English
PLN12S Notice of Potential Entitlement to Workers’ Compensation Death Benefits
Rev. 12/23
WORD Spanish
PLN14 Notice of Continuing Investigation
Rev. 07/23
WORD English
PLN14S Notificación de Investigación en Curso
Rev. 07/23
WORD Spanish
SF025 Fire Extinguisher Certificate of Registration Application
New Companies and New Branch Offices
PDF English
SF026 Fire Extinguisher License Application
PDF English
SF027 Fire Extinguisher Apprentice Permit Application
PDF English
SF028 Application to Revise or Transfer All Types of Fire Extinguisher Licenses
PDF English
SF031 Fire Alarm Certificate of Registration Application
New Companies and New Branch Offices
PDF English
SF032 Individual Application for All Types of Fire Alarm Licenses
PDF English
SF033 Application to Revise or Transfer All Types of Fire Alarm Licenses
PDF English
SF035 Fire Alarm Installation Certificate
PDF English
SF036 Fire Sprinkler Responsible Managing Employee (RME) License Application
PDF English
SF037 Fire Sprinkler Certificate of Registration Application
New Companies
PDF English
SF038 Revision/Transfer Application for Individuals
PDF English
SF041 Contractor's Material and Test Certification for Aboveground Piping
PDF English
SF042 Contractor's Material and Test Certification for Underground Piping
PDF English
SF043 Application for Fireworks License and / or Permit
Distributors, Jobbers, Manufacturers, Wildlife, Agricultural and Industrial Permit
PDF English
SF044 Application for Class B Fireworks Singular or Multiple Display Permit
PDF English
SF045 Pyrotechnic, Special Effects and Flame Effects Operator's License Application
PDF English
SF047 Application for Retail Fireworks Permit
PDF English
SF054 Branch Office Update Form
PDF English
SF084 Fire Alarm Certificate of Registration Renewal Application
PDF English
SF086 Renewal Application - Fire Extinguisher Certificate of Registration
Renewal of companies and branch offices
PDF English
SF087 Renewal Application - Hydrostatic Testing Certificate of Registration
PDF English
SF088 Renewal Application - Fire Sprinkler Certificate of Registration
PDF English
SF091 Renewal Application - Fireworks License
Distributors, Jobbers, Manufacturers
PDF English
SF094 Individual License Renewal Application for All Types of Fire Alarm Licenses
PDF English
SF099 Renewal Application - Fire Extinguisher License
Renewal of Individual Licenses
PDF English
SF100 Renewal Application - Fire Sprinkler Responsible Managing Employee
PDF English
SF104 Renewal Application - Fireworks Operator's License
PDF English
SF146 Texas Fire Department Identification (FDID) Number Request Application
PDF English
SF205 Fire Extinguisher System Installation Certification
PDF English
SF222 Retail Fireworks Indoor Site Information Form
PDF English
SF223 Fireworks Incident Report Form
A form to assist licensees and permitees in reporting an unauthorized fireworks explosion as required by 28TAC §34.819(d) and (c).
PDF English
SF227 Company Information Update Form
To update company address and authorized signatures
PDF English
SF228 Licensed Employee Termination Notice
PDF English
SF230 Fireworks Company Information Update Form
PDF English
SF246 Fire Alarm Training School Approval Application
Alarm Training Form
PDF English
SF247 Fire Alarm Instructor Approval Application
Alarm Instructor Form
PDF English
SF250 Fire Standard Compliant Cigarette Manufacturer Form
Certification by Manufacturer
PDF English
SF251 Fire Standard Compliant Cigarette Manufacturer Form
Application for Fire Standard Compliant Cigarette Marking Approval
PDF English
SF254 Fire Alarm Training School Renewal Application
PDF English
SF255 Fire Alarm Instructor Renewal Application
PDF English
SF259 Fire Safety Inspection Request Form
PDF English
SF261 Supplemental Criminal History Information
PDF English
SF265 Application Fee Exemption Form - Armed Services
PDF English
SF266 Fire Suppression Rating Oversight Complaint Form
PDF English
SF272 Application to Revise All Types of Individual Fireworks Licenses
PDF English
SF300 Course Location and Schedule
PDF English
SF400 Extinguisher Fixed Support System
PDF English
SF500 Applicant's Employer Information
PDF English
SF525 Fire Sprinkler Non-Resident Responsible Managing Employee (RME-G) Application Questions
PDF English
SF550 Fire Sprinkler Non-Resident Responsible Managing Employee-Underground Fire Main (RME-U) Application Questions
PDF English
SF600 Fireworks Online Application Supplement
PDF English
SN002 Notice to HMO Enrollees: Have a complaint about your HMO?
PDF English
SN002s ¿Tiene una queja relacionada con su HMO?
PDF Spanish
SN003 Workers Comp Network Sample Contingency Plan
PDF English
SN004 Workers Comp Net Sample Employee Acknowledgment Form
PDF English
SN005 Workers Comp Net Employee Acknowledgment Form
PDF Spanish
SN006 Workers Comp Net Sample Employee Acknowledgment Form - Chinese
PDF Chinese
SN007 Workers Comp Net Sample Employee Acknowledgment Form
PDF Vietnamese
SN008 Workers Comp Network Sample QI Report
PDF English
SN009 Sample URA Adverse Determination Notice, Health
PDF English
SN010 Sample URA Adverse Determination Notice, Specialty Health
PDF English
SN011 Sample URA Adverse Determination Notice, Workers Comp Net
PDF English
SN012 Sample URA Adverse Determination Notice, Workers Comp Non-Network
PDF English
SN013 Contract List
PDF English
SN014 Delegated Entity Data Form
Sample format for use by HMOs and WC HCNs when submitting delegation agreements to the Texas Department of Insurance
PDF English
Sample Notice Notice of Underpayment of Income Benefits
Rev. 12/11
PDF English
Sample Notice Aviso de Pago Insuficiente de los Beneficios de Ingresos
Rev. 12/11
PDF Spanish

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