Form FIN469 "Texas Workers' Compensation Self-insurance Group (Sig) Termination of Certificate of Approval Checklist" - Texas

What Is Form FIN469?

This is a legal form that was released by the Texas Department of Insurance - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2016;
  • The latest edition provided by the Texas Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form FIN469 by clicking the link below or browse more documents and templates provided by the Texas Department of Insurance.

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Download Form FIN469 "Texas Workers' Compensation Self-insurance Group (Sig) Termination of Certificate of Approval Checklist" - Texas

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FIN469 | 1216
TEXAS WORKERS’ COMPENSATION SELF-INSURANCE GROUP (SIG)
TERMINATION OF CERTIFICATE OF APPROVAL CHECKLIST
A Certificate of Approval remains in effect until terminated at the request of the group or revoked by the Commissioner of Insurance (“the
Commissioner”). The Commissioner may not grant the request of any group to terminate its Certificate of Approval unless the group has insured
or reinsured all incurred workers’ compensation obligations with an authorized insurer under an agreement filed with and approved in writing
by the Commissioner prior to the termination of the Certificate of Approval.
Please submit the following documentation:
1. SIG notification form (see FIN468)
2. Evidence that workers’ compensation obligations, claims, and related expenses have been insured or
reinsured.
3. If the workers’ compensation obligations are to be insured, submit a copy of the proposed insurance policy
issued by a Texas authorized workers’ compensation insurance carrier.
4. If the workers’ compensation obligations are to be reinsured, submit a copy of the proposed assumption
reinsurance arrangement with a Texas authorized workers’ compensation insurance carrier.
5. Documentation listing all SIG members, both past and present, and the date these members left the SIG,
and the name of their new insurance carrier.
6. A certified copy of minutes of the SIG’s Board of Director’s meeting approving the termination of the SIG’s
Certificate of Approval.
7. An affidavit signed by the President of the SIG, the Board of Directors, and the President of the SIG’s
Administrator, attesting that, to the best of their knowledge, there is no pending litigation or related
contingent liabilities.
Texas Department of Insurance | www.tdi.texas.gov
1/1
FIN469 | 1216
TEXAS WORKERS’ COMPENSATION SELF-INSURANCE GROUP (SIG)
TERMINATION OF CERTIFICATE OF APPROVAL CHECKLIST
A Certificate of Approval remains in effect until terminated at the request of the group or revoked by the Commissioner of Insurance (“the
Commissioner”). The Commissioner may not grant the request of any group to terminate its Certificate of Approval unless the group has insured
or reinsured all incurred workers’ compensation obligations with an authorized insurer under an agreement filed with and approved in writing
by the Commissioner prior to the termination of the Certificate of Approval.
Please submit the following documentation:
1. SIG notification form (see FIN468)
2. Evidence that workers’ compensation obligations, claims, and related expenses have been insured or
reinsured.
3. If the workers’ compensation obligations are to be insured, submit a copy of the proposed insurance policy
issued by a Texas authorized workers’ compensation insurance carrier.
4. If the workers’ compensation obligations are to be reinsured, submit a copy of the proposed assumption
reinsurance arrangement with a Texas authorized workers’ compensation insurance carrier.
5. Documentation listing all SIG members, both past and present, and the date these members left the SIG,
and the name of their new insurance carrier.
6. A certified copy of minutes of the SIG’s Board of Director’s meeting approving the termination of the SIG’s
Certificate of Approval.
7. An affidavit signed by the President of the SIG, the Board of Directors, and the President of the SIG’s
Administrator, attesting that, to the best of their knowledge, there is no pending litigation or related
contingent liabilities.
Texas Department of Insurance | www.tdi.texas.gov
1/1