TDI Forms

This is one of several pages linking to a central repository of forms used by TDI customers. Use the search or Forms by Type links on the Forms Home Page or scan through our form listings.

Agent/Adjuster Forms
Agent/Adjuster Application Forms | Continuing Education Forms | Information Update Forms

Third Party Administrator Licensing Forms
Forms Used by TPAs | Forms Used by Insurers / HMO's Acting as TPAs | Checklists | Forms Used to File ERISA Exemptions |
Forms Used by TPAs Administering Multi-Jurisdictional Impaired Insurance Company Policies / Claims | Other Forms

Premium Finance Company Licensing Forms

 

Web Enabled Agent/Adjuster Application Forms

TDI Form Number	Description	File Format
	Electronic Non-resident Application - fill in and send on-line. (Links to NIPR, at the Texas instruction page for the electronic application. That page is linked to a Use Agreement page. The "Agree" button links to the actual application.)	Web Enabled
	Licensing Application to Renew License Renew License Online	Web Enabled

Agent/Adjuster Application Forms

TDI Form Number	Description	File Format
LHL202	Licensing Corporate Insurance Agents Bond (AKA Insurance Agency Bond) Method of showing proof of financial responsibility to obtain corporate license.	PDF
LHL206	Licensing - Individual Application for Insurance License Used by individuals not required to qualify by examination. Previously, form number LI011.	PDF
LHL236	Request for Letter(s) of Certification Agents, Adjusters, & Entities	PDF
LHL249	Licensing Application for Insurance Agency License Used by corporations, partnerships, depository institions and other business entity eligible for an insurance agency license under the provisions of the Texas Insurance Code.	PDF
LHL250	Annual Nonresident Public Insurance Adjuster Affidavit Fill-in On Screen and Print	PDF
LHL256	Licensing Public Insurance Adjuster Bond 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 §19.705.	PDF
li004	Speciality Insurance License Application	PDF
TDIFastForm	Fingerprint Applicant Services of Texas (FAST) form	PDF

 

Continuing Education Forms

TDI Form Number	Description	File Format
LHL212	Application for Provider Registration Application to become a CE provider.	PDF
LHL213	Application for Course Certification Application for certification of CE course.	PDF
LHL216	CE Exemption or Extension Application for licensee CE Exemption or Extension.	PDF
LHL240	Course Assignment Form Allows an existing provider to assign the right to give its course to another existing provider. Both must have active provider registrations.	PDF
LHL257	CE Automatic Fines Transmittal Continuing Education Fines	PDF
LHL367	Provider Renewal and Information Change Form Application for Provider Renewal or Change of Contact Information.	PDF
LHL386	Provider Audit Affidavit Used only by continuing education providers	PDF

Additional Continuing Education Forms

TDI Form Number	Description	File Format
	CE Example Course Evaluation	PDF

 

Information Update Forms

TDI Form Number	Description	File Format
LHL203	Registration of Assumed Name/Branch Locations/Entity Name Change Commonly known as form LDTL	PDF
LHL208	ISR Transfer/Cancel Employment Form	PDF
LHL238	Biographical Form Entity/Change of Control	PDF
LHL388	Branch Office Address Change Request	PDF
LHL389	Licensee Name/Address Change Request Form	PDF

 

Forms Used by TPAs

TDI Form Number	Description	File Format
LHL078	Licensing Assumed Name Certificate Used to obtain DBA for a TPA.	PDF
LHL079	Licensing Application for Certificate of Authority To do business as a TPA in Texas.	PDF
LHL080	Licensing Third Party Administrator Annual Report Form used to submit changes in TPA ownership and organization.	PDF
LHL081	Licensing Biographical Affidavit Biographical information for officers and directors for TPAs. This form is similar to Financial's Biographical Affidavit.	PDF
LHL082	Licensing Service of Process Attesting that the named person appear before notary.	PDF
LHL088	Licensing Annual Report Exhibits These exhibits are used to collect information on the plans administered in Texas during the preceding year. LHL088 includes four exhibits: Exhibit A - Fully Insured Plans; Exhibit B - Self-Funded Political Subdivision Plans; Exhibit C - Self-Funded ERI	EXCEL
TPAFRMARINSTR	Instructions for LHL080	PDF

Forms Used by TPAs

TDI Form Number	Description	File Format
FIN300	Company Name Application	PDF
FIN306	Officers and Directors Page Compliance with statutes	PDF

 

TPA Checklists

TDI Form Number	Description	File Format
LHL177	Licensing Checklist for TPA Name Change Checklist	PDF
LHL177	TPA Name Change Checklist	WORD
LHL178	Licensing Checklist for TPA License Checklist	PDF

 

Forms Used by Insurers / HMO's Acting as TPAs

TDI Form Number	Description	File Format
LHL083	Licensing Application of Certain Insurers and Health Maintenance Orgainzations Notifies TDI that certain insurers or HMOs are operating as administrators.	PDF
LHL084	2006 Third Party Administrator Annual Report Annual Report, aka TPA Form 6a.	PDF
LHL088	Licensing Annual Report Exhibits These exhibits are used to collect information on the plans administered in Texas during the preceding year. LHL088 includes four exhibits: Exhibit A - Fully Insured Plans; Exhibit B - Self-Funded Political Subdivision Plans; Exhibit C - Self-Funded ERI	EXCEL
TPAFRMARINSTR	Instructions for LHL080	PDF

 

 

Forms Used to File ERISA Exemptions

TDI Form Number	Description	File Format
LHL085	Licensing Notification of Exemption Form Notifies TDI that TPA, insurer, or HMO is only administering self-funded ERISA business.	PDF

 

 

Forms Used by TPAs Administering Multi - Jurisdictional Impaired Insurance Company Policies / Claims

TDI Form Number	Description	File Format
LHL086	Licensing Application for a Limited Certificate of Authority Used by TPAs, licensed in at least two other states, to obtain a limited certificate of authority to administer multi-jurisdictional impaired insurance company estates in Texas. This form is also referred to as TPA Form No. 8.	PDF
LHL087	Licensing Annual Report for Limited Certificate of Authority Annual report submitted by TPAs, that are licensed in at least two other states, for each limited certificate of authority to administer multi-jurisdictional impaired insurance company estates in Texas. This form is also referred to as TPA Form No. 8A.	PDF

 

 

Premium Finance Company Licensing Forms

TDI Form Number	Description	File Format
LHL102	Licensing Biographical Affidavit Collects Biographical Information	PDF
LHL103	Licensing Premium Finance Company License Application (for new license) Part of application process	PDF
LHL104	Licensing List of other States of Licensure Shows other states where company is licensed	PDF
LHL105	Licensing Premium Finance License Renewal Application Renew Premium Finance License	PDF
LHL106	Licensing Appointment of Statutory Agent and Consent to Service Notifies TDI who the agent for service will be.	PDF
LHL107	Licensing List of Principals Lists all officers, director and manager.	PDF
LHL108	LHL108 - Licensing Premium Finance Supplemental Application (for additional location, relocation, name change and ownership change) Notify TDI of any change in Premium Finance company.	PDF
LHL109	Licensing Application for an Insurance Premium Finance Company License by a Bank or Savings and Loan Association Applications for banks, savings and loans to get license in Texas	PDF
LHL110	Licensing Questionnaire Form must be filled out as part of application process.	PDF
LHL260	Licensing Premium Finance Comparison Disclosure Form Texas Automobile Insurance Plan Association (TAIPA) Disclosure Form	PDF

Additional Premium Finance Company Licensing Forms

TDI Form Number	Description	File Format
PFSchA	Additional Location	PDF
PFSchB	Relocation	PDF
PFSchC	Name Change	PDF
PFSchD	Change of Ownership	PDF

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For more information contact: License@tdi.state.tx.us