The following forms are to be used in conjunction with the
rules adopted under this chapter. Copies of these forms may be obtained
by contacting the Company Licensing and Registration Office, Mail
Code 103-CL, Texas Department of Insurance, P.O. Box 149104, Austin,
Texas 78714-9104, or from the department's website at www.tdi.texas.gov.
Each HMO or other person or entity must use the form or forms required
by this title as appropriate to its particular activities. The forms
are listed as follows:
(1) Name Application Form, (rev. 03/14);
(2) Application for a Certificate of Authority to do
business in the State of Texas, (rev. 09/04);
(3) State of Texas Officers and Directors Page, TDI
Form FIN306, (rev. 06/10);
(4) State of Texas Biographical Affidavit, NAIC UCAA
Form 11, (rev. 04/13);
(5) HMO Certification and Transmittal Form, TDI Form
LHL 259, (rev. 07/14);
(6) Reconciliation of Benefits to Schedule of Charges
Form, TDI Form LHL 654, (rev. 01/13);
(7) Statutory Deposit Transaction Form, Form No. FIN407
(rev.11/15); and
(8) Declaration of Trust Form, Form No. FIN453 (rev.11/15).
|
