Texas Health Insurance Risk Pool Application Package

The Pool's Application package is provided below in a downloadable Adobe Reader file to allow you to print off the forms needed to complete and submit your application for coverage. 

The Pool's Application package consists of the following documents:

• Application Package Cover Letter 
• Outline of Coverage 
• Application Form  
• Application Checklist 
• Applicant Employment Information Forms 

After you have printed the above set of documents, please refer to the "Premium Rates" page of this web site for current premium rates and instructions to help you determine your specific premium rate. After you have completed all required forms, mail or deliver your original signed document package and premium deposit to the Pool's Administrator at the address shown on the Application.  The effective date of your coverage will be the first day of the month following the date your application is approved, unless you request a later date.  Please allow adequate application processing time (at least 10 days for complete applications).  Incomplete applications will delay processing and your coverage effective date. Should you have any questions regarding the application, please contact the Pool's Administrator at  1-888-398-3927. 

TAA/PBGC Eligibles:  If you have been certified as a TAA/PBGC-eligible, and wish to enroll in the Pool to claim your tax credit, contact the Pool's Administrator at 1-888-398-3927 to request a TAA application package.

Note that you must have the latest version of Adobe Reader to view and print the Application and Rates correctly.  For free software go to:  Adobe Reader

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