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Listing of all TDI forms
TDI form number	Description	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
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
AH026	Exhibit A — Permissible Exclusions in Individual Accident and Health Policies	PDF	English
AS004	Accounting Texas Overhead Assessment	PDF	English
CCRA01/FIN382	CCRC Form 1 - Application for certificate of authority to do business in the State of Texas under Health and Safety Code Section 246.022	PDF	English
CCRC01a/FIN604	CCRC Form 1a - Application for authority to offer continuing care in residence in Texas under Health and Safety Code Section 246.0025(b).	PDF	English
CCRC02/FIN383	CCRC Form 2 - Application for Commissioner approval to release excess loan reserve escrow fund amounts under Health and Safety Code Section 278.078	PDF	English
CCRC03/FIN384	CCRC Form 3 - Officers and directors page	PDF	English
CCRC04/FIN385	CCRC Form 4 - Biographical data form	PDF	English
CCRC04a/FIN386	CCRC Form 4A - Biographical data form for a not-for-profit CCRC board members	PDF	English
CCRC05/FIN387	CCRC Form 5 - Delivery of disclosure statement	PDF	English
CCRC06/FIN388	CCRC form 6 - Format for Disclosure Statement for Continuing Care Facility	WORD	English
CCRC06a/FIN389	CCRC Form 6A - Instructions for preparation a continuing care retirement community disclosure statement for filing with TDI	PDF	English
CCRC06b/FIN605	CCRC form 6B - Format for Disclosure Statement for Continuing Care Facility	WORD	English
CCRC07/FIN390	CCRC Form 7 - Change of control statement for CCRC	PDF	English
CCRC08/FIN391	CCRC Form 8 - Certification of changes to disclosure statement	PDF	English
CCRC09/FIN392	CCRC Form 9 - Notice of request to release entrance fee escrow funds	PDF	English
CCRC10/FIN393	CCRC Form 10 - Notice of request to release funds from the reserve fund escrow account	PDF	English
CCRC11/FIN394	CCRC Form 11 - Notice by provider of re-payment of previously released funds to the reserve fund escrow account	PDF	English
CCRC12/FIN395	CCRC Form 12 - Affidavit of re-payment of previously released funds to the reserve fund escrow account	PDF	English
CCRC13/FIN396	CCRC Form 13 - Notice of lien	PDF	English
CCRC14/FIN397	CCRC Form 14 - Calculations concerning conditions	PDF	English
CCRC14a/FIN607	CCRC Form 14a - Provider request for release of continuing care residence entrance fee escrow funds	PDF	English
CCRCFR/FIN381	CCRC Filing Requirements for Certificate of Authority	PDF	English
CCRCRE/FIN403	CCRC Release Escrow Checklist	PDF	English
CCRCNC/FIN398	CCRC Name Change Checklist	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. 10/24. This form is submitted by the carrier to DWC.	PDF	English
DWC001S	Employer’s first report of injury or illness (for state employees) Rev. 01/25	PDF	English
DWC002	Employer’s report for reimbursement of voluntary payment Rev. 10/24	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	Non-subscriber notice to Division of Workers’ Compensation Rev. 01/25 - static version for mailing and faxing	PDF	English
DWC005S	Notificación de empleador no suscriptor a la División de Compensación para Trabajadores Rev. 01/25	PDF	Spanish
DWC006	Supplemental report of injury Rev. 10/24	PDF	English
DWC007	Employer’s report of noncovered employee’s work-related injury or illness Rev. 01/25	PDF	English
DWC007S	Reporte del empleador para lesiones o enfermedades relacionadas con el trabajo de los empleados sin cobertura Rev. 01/25	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	Governmental entity coverage information Rev. 08/24	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	Spanish
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. 11/24	PDF	English
DWC032S	Solicitud para obtener un examen por parte de un médico designado Rev. 11/24	PDF	Spanish
DWC033	Request to reduce income benefits due to contribution Rev. 05/22	PDF	English
DWC038	Application for lifetime income benefits (LIBs) Rev. 11/24	PDF	English
DWC038S	Solicitud para recibir beneficios de ingresos de por vida (LIBs) Rev. 11/24	PDF	Spanish
DWC039	First responder’s annual certification for lifetime income benefits (LIBs) Rev. 11/24	PDF	English
DWC039S	Certificación anual de los beneficios de ingresos de por vida (LIBs) para el personal de respuesta inmediata Rev. 11/24	PDF	Spanish
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	Supplemental Income Benefits (SIBs) Application Rev. 07/24	PDF	English
DWC052S	Solicitud para recibir beneficios de ingresos suplementarios (SIBs) Rev. 07/24	PDF	English
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
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	PDF	English
DWC068	Designated doctor examination data report Rev. 6/23	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. 07/24	PDF	English
DWC105	Accident prevention services worksheet Rev. 07/24	WORD	English
DWC105	Accident prevention services worksheet Rev. 07/24	PDF	English
DWC105	Accident prevention services worksheet Rev. 07/24	WORD	English
DWC109	Accident prevention services annual report Rev. 07/24	PDF	English
DWC109	Accident prevention services annual report Rev. 07/24	WORD	English
DWC109	Accident prevention services annual report Rev. 07/24	PDF	English
DWC109	Accident prevention services annual report Rev. 07/24	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. 11/25	PDF	English
DWC154S	Quejas de Compensación para Trabajadores Rev. 11/25	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 Filing Requirements 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/Fraternal Insurers Filing Requirements Checklist 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 Companies Filing Requirements 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
FIN230	Annuity PBR Statement Exemption Form	PDF	English
FIN231	Life Principle-Based Reserving (PBR) Statement of Exemption	PDF	English
FIN232	Captive Actuarial Opinion Waiver Affidavit	PDF	English
FIN233	Actuarial Opinion Exemption Affidavit	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 Supplement	PDF	English
FIN300	Company Name Reservation 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	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
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
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
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 (Li004, LHL207)	PDF	English
FIN517	CE Exemption or Extension Application for licensee CE Exemption or Extension. 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 Form for individuals changing state of residency to TX. Agencies must apply for a resident license via Sircon or the National Insurance Producer Registry.	PDF	English
FIN599	Cybersecurity Checklist	PDF	English
FIN609	Annual Verification of Fidelity Bond Coverage (HMO Employee)	PDF	English
FIN610	Officers and Employees of Management Contractor: Verification of Fidelity Bond Coverage	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
FIN705	Public Insurance Adjuster (PIA) Checklist	PDF	English
FIN706	Multiple Employer Welfare Arrangement (MEWA) For MEWAs electing to comply with Insurance Code Section 846.0035.	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 To be completed by authorized appointing official.	PDF	English
FINT10	Title Insurance Agent or Direct Operation Appointment To be completed by authorized appointing official.	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 Used for Title Agency information updates	PDF	English
FINT132	Application for Texas Escrow Officer's License For fastest processing, apply online at Sircon and refer to important information on the TDI Escrow Officer web page.	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
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
LAC028	Replacement of Life Insurance or Annuities	PDF	English
LAC029	Notice Regarding Replacement - Replacing Your Life Insurance Policy or Annuity	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 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 This form must be used beginning July 1, 2019.	PDF	English
LHL138	Patient Health Plan Coverage	PDF	English
LHL139	Enrollee's Other Health Plan Coverage	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
LHL714	IRO Notice of Decision Template - Rescission	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 Rate 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 September 1, 2020 (2018 building code).	PDF	English
PC437	Third Party Evaluation Reports Request to post on TDI website	PDF	English
PC440	Exhibit 3PD — Third-Party Data Disclosure	PDF	English
PC441	Exhibit 3PM — Third-Party Models Disclosure	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. 11/24	WORD	English
PLN04S	Notice of Eligibility for Lifetime Income Benefits Rev. 11/24	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. 11/24 (for use on or after 11/21/24)	WORD	English
PLN07S	Notice of Change of Indemnity Benefit Type Rev. 11/24 (for use on or after 11/21/24)	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
SF001	State Fire Marshal’s Office Address Change Request Form	PDF	English
SF025	Fire Extinguisher Certificate of Registration Application New Companies and New Branch Offices	PDF	English
SF026	Individual Application for All Types of Fire Extinguisher Licenses	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	Individual Application for All Types of Fire Sprinkler Licenses	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 a Fireworks License 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	Individual Application for a Pyrotechnic, Special Effects, and Flame Effects Operator's License	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	Certification by Manufacturer for Fire Standard Compliant Cigarette (FSCC)	PDF	English
SF251	Application for Fire Standard Compliant Cigarette Marking Approval Or Modification of 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	Criminal History Information Supplemental Form	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
SN019	HMO Major Medical Access Plan Template	EXCEL	English
SN020	HMO Attempt to Contract Template	EXCEL	English
SN021	HMO Dental Access Plan Template	EXCEL	English
SN022	HMO Provider List Template	EXCEL	English
SN023	HMO Vision Access Plan Template	EXCEL	English
SN024	HMO Vision Provider List Template	EXCEL	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