Section 11.1001 - Required FormsThe 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).28 Tex. Admin. Code § 11.1001
The provisions of this §11.1001 adopted to be effective December 11, 1984, 9 TexReg 6807; amended to be effective December 4, 1987, 12 TexReg 4364; amended to be effective August 17, 1992, 17 TexReg 5360; amended to be effective November 2, 1998, 23 TexReg 11347; amended to be effective February 24, 2005, 30 TexReg 854; Adopted by Texas Register, Volume 42, Number 16, April 21, 2017, TexReg 2251, eff. 8/1/2017