How to Fill Out Texas TDI Form NAIC-A (w/Examples) + FAQs

Texas TDI Form NAIC-A is the Biographical Affidavit that every officer, director, key manager, and 10%-or-greater shareholder of an insurance company, HMO, premium finance company, or insurance holding company must file with the Texas Department of Insurance when seeking licensure, approval of a Form A acquisition, redomestication, or appointment to a regulated entity. The form is part of the NAIC Uniform Certificate of Authority Application (UCAA) suite, branded as NAIC Biographical Affidavit (Form 11), and Texas accepts the current NAIC-published revision dated August 2022.

Filers usually meet this form during a regulatory transaction with a tight closing deadline, and a single missing answer can stall a multi-million-dollar deal for weeks. The Texas Department of Insurance reviews more than 1,200 company licensing filings each year, and TDI staff have publicly noted that incomplete biographical affidavits are among the top three reasons company filings are returned without action.

📝 How to complete every box on Form NAIC-A line by line, with sample wording you can copy.
🔍 What background, residency, employment, and disclosure history TDI actually verifies behind the scenes.
⚖️ The Texas statutes and 28 TAC rules that turn an inaccurate affidavit into a license-killing problem.
🧾 Three full filled-out walkthroughs for the most common Texas filer profiles.
📬 Every accepted filing channel, fee, processing time, and proof-of-filing you should keep.

What Form NAIC-A Is and Who Must File It

Form NAIC-A is a sworn, notarized statement of personal, professional, financial, and regulatory history used by state insurance regulators to decide whether an individual is competent, trustworthy, and financially responsible enough to control or direct an insurer. The Texas version is the NAIC standard form adopted by reference under the TDI Company Licensing and Registration page, and it travels with nearly every Texas filing that involves a change in control, new licensure, or addition of a key person.

Texas requires the affidavit under several statutory hooks. The Texas Insurance Code Chapter 823 governs insurance holding company systems and demands biographical detail on every person who will control a Texas-domestic insurer. The Texas Insurance Code Chapter 801 and Chapter 841 require the same disclosure for organizers and officers of new domestic life and stock insurers. HMO applicants supply the affidavit under the Texas Insurance Code Chapter 843, and premium finance company applicants under Chapter 651.

Who must file it? Every director, every executive officer (CEO, president, CFO, COO, general counsel, chief actuary, chief compliance officer, chief underwriting officer, chief claims officer), every trustee, every person who will own or control 10% or more of the voting securities of the regulated entity, and any other key person TDI specifically requests. Each individual files their own affidavit; group affidavits are not allowed. The form is also reused for Form A acquisitions of control filings under 28 TAC §7.204, where the acquiring party’s directors and officers each submit their own.

Before You Start: Documents and Information You Need

Open the form only after you have gathered every supporting record. The affidavit asks you to recall 10 years of residences, 10 years of employers, every license you have ever held, every regulatory inquiry you have ever faced, and every personal financial event of consequence, and gaps trigger TDI follow-up letters that delay your filing.

Use this pre-filing checklist before you begin typing. Each item explains why it matters and what happens if you skip it.

Government-issued photo ID (driver license or U.S. passport) — TDI cross-checks the legal name on the affidavit against your ID, and a mismatched middle name forces a corrected, re-notarized refile.
Social Security number and date of birth — these route to the third-party vendor’s background check; a transposed digit returns a “no record found” report and stalls the filing.
Last 10 years of residential addresses with exact move-in/move-out dates — TDI’s vendor verifies residency history against credit headers, and unexplained gaps generate a clarification request.
Last 10 years of employment history with employer addresses, supervisor names, and dates — these support the business affiliation disclosures in Question 18 and the employment timeline in Question 16.
Every professional license number ever held (insurance producer, securities, legal, CPA, real estate, banking) with issuing state and current status — Question 20 demands all of them, lapsed and active.
Court records for every civil suit, criminal charge, bankruptcy, lien, or judgment in your past, regardless of outcome — Texas requires disclosure even of dismissed and expunged matters unless statute specifically excludes them.
Regulatory action documents from any insurance, securities, banking, or professional licensing authority that ever investigated, fined, suspended, or denied you — Questions 25–30 cover these and even informal inquiries must be disclosed.
A current resume or CV — TDI requires it as an attachment, and the dates on the resume must match the dates on the affidavit exactly.
Notary access with a Texas-commissioned (or other-state-commissioned) notary public — the affidavit is sworn, not merely signed.
Authorization for a third-party background investigation from one of the NAIC-approved vendors (currently Business Information Group and Superior Group, with Business Information Group’s UCAA portal the most-used).

The affidavit and its attachments must be dated within six months of TDI’s receipt date under the NAIC UCAA Instructions, so do not start collecting signatures until your transaction timeline is firm.

Where to Get the Form and How to Access It

The official, current NAIC Biographical Affidavit (Form 11), which TDI accepts as Form NAIC-A, is hosted on the NAIC’s UCAA page. Download the PDF directly from the NAIC UCAA forms library under “Form 11 — Biographical Affidavit.” Texas does not maintain a separate state-branded PDF; the TDI Company Licensing page instructs filers to use the NAIC version.

The form is a fillable PDF designed for Adobe Acrobat or Adobe Reader. Open it in a desktop PDF editor, not a browser preview, because browser-rendered PDFs frequently strip the field formatting and cause your typed answers to vanish on save. Filers using macOS Preview have repeatedly lost data because Preview does not preserve the form’s JavaScript validation; use Adobe Reader instead.

Texas accepts the affidavit through three channels: paper original delivered to TDI’s Austin office, electronic submission through the NAIC’s electronic UCAA portal for certain expansion and corporate amendment filings, and inclusion as an exhibit to a Form A holding-company filing under 28 TAC §7.204. Each channel still requires a wet-ink notarized original, even when the rest of the filing is electronic.

The current revision is dated August 2022, printed on the lower-left corner of every page. Confirm the revision before you begin; older revisions are routinely rejected because they omit cybersecurity-related disclosure prompts that the NAIC Financial Condition (E) Committee added in 2022.

Step-by-Step: How to Fill Out Form NAIC-A Line by Line

The affidavit runs 16 pages with roughly 33 numbered questions, plus a notary block, an authorization for release, and a fingerprint card attachment. Work through the form in order. Do not leave any field blank; if a question does not apply, write N/A rather than skipping it, because TDI treats blank fields as unanswered and returns the filing.

Header: Affiant Identification and State Filed In

The header asks for the name of the company, the state in which the affidavit is filed, and a checkbox for the type of filing.

Plain English. This identifies which company you are joining, which state regulator is reviewing the affidavit, and what kind of transaction triggered it.
How to answer. Type the regulated entity’s full legal name as registered with the Texas Secretary of State, write Texas in the state line, and check the single box that matches your filing (Primary Application, Expansion, Corporate Amendment, Form A, or Other).
Example entry. Lone Star Mutual Insurance Company / Texas / Form A.
Nuance. If the affidavit will accompany filings in multiple states (a UCAA expansion to ten states), file a separate original in each state with that state’s name in the header; one affidavit cannot cover multiple states simultaneously.
Common mistake and consequence. Filers often write the parent holding company name instead of the regulated insurer’s name, which causes TDI to reject the affidavit because it cannot tie the affiant to the entity in its licensing system.
Misconception. Many filers think the header is informational only; it is actually a jurisdictional declaration, and an incorrect state name renders the notarization defective.

Question 1: Affiant’s Full Legal Name

Plain English. Your complete legal name, including middle name and any suffix.
How to answer. Enter your name exactly as it appears on your Social Security card and current government ID, in the order First, Middle, Last, Suffix.
Example entry. Maria Elena Lopez-Hernandez.
Nuance. If you go by a hyphenated, anglicized, or married name that differs from your Social Security record, list the SSA name here and capture aliases in Question 2.
Common mistake and consequence. Using a nickname (Mike instead of Michael) causes the background check to return “no record found,” and the filing is held until a corrected affidavit arrives.
Misconception. Filers often think middle initial is enough; the affidavit explicitly demands the full middle name to disambiguate from same-named individuals in court and credit records.

Question 2: Other Names Used (Aliases, Maiden, Prior Married)

Plain English. Every other name you have ever been known by.
How to answer. List maiden names, prior married names, anglicized names, professional pseudonyms, and stage names, with the date range each name was used.
Example entry. Maria Elena Hernandez (1985–2009, maiden); Mary Lopez (2009–2014, professional).
Nuance. Court records and credit headers index by name, so omitting a maiden name causes the background vendor to miss a matching record and TDI later finds it independently.
Common mistake and consequence. Filers omit short-lived first-marriage surnames; when TDI’s vendor surfaces them, the affidavit is treated as misleading and the filer must explain in writing.
Misconception. Some filers believe legally changed names “do not count”; the affidavit asks for all names used, regardless of legal status.

Question 3: Date and Place of Birth

Plain English. When and where you were born.
How to answer. Write the date in MM/DD/YYYY format and the city, state or province, and country of birth.
Example entry. 03/14/1972, Monterrey, Nuevo León, Mexico.
Nuance. Foreign-born affiants should use the country name in English (Mexico, not México) so vendor systems can match.
Common mistake and consequence. Writing “USA” without a state when birth occurred on a U.S. military base abroad causes a vendor mismatch; the correct entry names the host country and notes the base.
Misconception. Filers think the place of birth is cosmetic; it is actually used by federal-level criminal databases that require both date and place to confirm identity.

Question 4: Current Residence Address

Plain English. Where you live right now.
How to answer. Provide the full street address, city, state, ZIP, and country, plus the date you moved in.
Example entry. 4218 Bluebonnet Lane, Austin, TX 78745, USA, since 06/01/2021.
Nuance. A P.O. Box is never acceptable here; if you receive mail at a P.O. Box, list the physical address and add the P.O. Box separately under mailing address in Question 5.
Common mistake and consequence. Filers list a corporate apartment address from a recent relocation, but if they have not lived there at least 30 days, TDI’s vendor cannot verify and returns a delay notice.
Misconception. Some assume the residence address is private; the affidavit becomes part of TDI’s public file unless a confidentiality request is granted under Texas Insurance Code §823.011.

Question 5: Residences for the Last 10 Years

Plain English. Every place you have lived for the past decade.
How to answer. List each address with month-and-year move-in and move-out dates, in reverse chronological order, with no gaps.
Example entry. 4218 Bluebonnet Ln, Austin, TX (06/2021–present); 1102 Oak St, Houston, TX (08/2017–05/2021); 55 Riverside Dr, New York, NY (07/2014–07/2017).
Nuance. Overlap dates are acceptable for filers maintaining two residences (snowbird retirees, dual-state executives), but you must mark which was primary.
Common mistake and consequence. Forgetting a six-month corporate housing stint creates an unexplained gap, and TDI sends a clarification letter that adds 14–21 days to processing.
Misconception. Filers think only U.S. addresses are required; foreign addresses must be listed too, with country and postal code.

Question 6: Education

Plain English. Schools you have attended after high school.
How to answer. List each institution, location, dates of attendance, degree earned, and field of study.
Example entry. University of Texas at Austin, Austin, TX, 1990–1994, BBA Finance; Wharton School, Philadelphia, PA, 1996–1998, MBA.
Nuance. List schools you attended even if you did not graduate; attendance without a degree must still be disclosed.
Common mistake and consequence. Filers conceal a withdrawn enrollment thinking it is irrelevant, but the National Student Clearinghouse picks it up and the affidavit is flagged for misrepresentation.
Misconception. Continuing education and professional designations belong in Question 7, not here; mixing the two looks padded.

Question 7: Professional Designations and Memberships

Plain English. Industry credentials and association memberships.
How to answer. List each designation (CPCU, CLU, ChFC, FSA, ASA, FCAS, ACAS), the granting body, the year earned, and current status.
Example entry. CPCU, The Institutes, 2003, active; FSA, Society of Actuaries, 2008, active.
Nuance. Lapsed designations still belong here with status lapsed and the year of lapse.
Common mistake and consequence. Filers omit designations earned but never used in their current role; TDI considers the omission incomplete disclosure.
Misconception. General memberships (Rotary, alumni clubs) are not required; only industry-recognized designations and trade memberships matter.

Question 8: Present Employer and Position

Plain English. Your current job and title.
How to answer. List the employer’s full legal name, address, your job title, your direct supervisor, and your start date.
Example entry. Lone Star Mutual Insurance Company, 100 Congress Ave, Austin, TX 78701, Chief Financial Officer, reports to CEO Jordan Patel, since 02/15/2024.
Nuance. If you will assume the role only upon TDI approval, write contingent on approval next to the start date.
Common mistake and consequence. Filers list the parent holding company instead of the regulated subsidiary that triggered the affidavit, which confuses TDI’s reviewer.
Misconception. “Present employer” means the employer at the time of signing, not the one you are about to join.

Question 9: Employment History (Last 10 Years)

Plain English. Every job you have held in the past decade.
How to answer. List each employer in reverse chronological order with addresses, titles, dates, and reason for leaving.
Example entry. Big Three Reinsurance, New York, NY, SVP Finance, 03/2018–01/2024, left for new opportunity.
Nuance. Self-employment, consulting, and unpaid board service all count and need full disclosure.
Common mistake and consequence. Filers compress short stints into “various consulting,” and TDI returns the form requesting individual entries.
Misconception. Filers think the affidavit only cares about insurance jobs; it cares about every job, regardless of industry.

Question 10: Military Service

Plain English. Whether you have served in any country’s armed forces.
How to answer. Provide branch, rank at discharge, dates, and type of discharge (honorable, general, other than honorable, dishonorable, medical).
Example entry. U.S. Army, Captain, 06/1994–08/2000, honorable discharge.
Nuance. National Guard and Reserve service must be disclosed with active-duty periods called out separately.
Common mistake and consequence. Filers forget Reserve commissions earned through ROTC; the omission surfaces in the DD-214 review and triggers a misrepresentation flag.
Misconception. Foreign military service does not need to be hidden; it is fully disclosable and rarely disqualifying on its own.

Question 11: Regulated Entity Affiliations (Past and Present)

Plain English. Every insurance, securities, banking, or HMO entity you have served as officer, director, trustee, or 10%+ owner.
How to answer. Provide the entity name, your role, dates, jurisdiction of regulator, and whether the entity is currently in good standing.
Example entry. Acme Re Bermuda Ltd, Director, 2017–2022, Bermuda Monetary Authority, in good standing.
Nuance. Captive insurers, risk retention groups, and surplus lines brokers all count; do not limit the list to admitted carriers.
Common mistake and consequence. Filers omit short-lived advisory board roles; TDI treats undisclosed affiliations as evidence of lack of candor.
Misconception. Non-U.S. affiliations are still required even when the foreign regulator is informal.

Question 12: Stock Ownership in Regulated Entities

Plain English. Whether you own securities in any insurance or related regulated entity.
How to answer. State the entity, class of stock, number of shares, and percent of class outstanding.
Example entry. Lone Star Mutual Holdings Inc., common stock, 12,000 shares, 0.4% of class.
Nuance. Stock options, RSUs, and beneficial ownership through trusts must be disclosed even if not yet vested.
Common mistake and consequence. Filers omit spouse-held shares, but Texas Insurance Code §823.005 attributes spousal ownership for control determinations.
Misconception. Mutual funds and broad-based index funds are excluded; individual insurance carrier shares are not.

Question 13: Bankruptcy History

Plain English. Whether you have ever filed for personal or business bankruptcy.
How to answer. Provide the chapter, court, case number, dates, and disposition for each bankruptcy.
Example entry. Chapter 7, Southern District of Texas, Case No. 12-34567, filed 04/2012, discharged 09/2012.
Nuance. Disclosure is required even if the bankruptcy was decades ago and even if it has been removed from your credit report.
Common mistake and consequence. Filers think a discharged bankruptcy is “off the record”; the affidavit asks about lifetime history, and concealment is a separate violation under Texas Insurance Code §82.051.
Misconception. Business bankruptcies of an LLC you owned are personal disclosures here, even if you were not personally liable.

Question 14: Liens and Judgments

Plain English. Outstanding tax liens, civil judgments, or unsatisfied money judgments.
How to answer. List each lien or judgment with creditor, amount, filing court, date, and current status.
Example entry. IRS federal tax lien, Travis County, $24,500, filed 03/2019, satisfied 11/2020.
Nuance. Satisfied liens still require disclosure; the form asks about ever, not just outstanding.
Common mistake and consequence. Filers report only currently active liens, and TDI’s vendor surfaces satisfied ones, generating a clarification request.
Misconception. Mortgage liens and routine UCC filings are not required here; only judgment, tax, and mechanic’s liens.

Question 15: Civil Litigation

Plain English. Civil lawsuits in which you have been a party.
How to answer. List each case with caption, court, case number, your role, dates, and outcome.
Example entry. Smith v. Lopez, 250th Dist. Ct. Travis Cty., Cause No. D-1-GN-15-001234, defendant, filed 03/2015, dismissed 11/2015.
Nuance. Disclose dismissed and settled cases, including those settled with no admission of liability.
Common mistake and consequence. Filers omit divorce litigation; TDI does not require divorce details unless they include allegations of fraud, but the case must be listed.
Misconception. Class action membership as a passive plaintiff does not need disclosure; named-plaintiff status does.

Question 16: Criminal History

Plain English. Any arrest, charge, indictment, or conviction.
How to answer. Disclose every criminal matter regardless of disposition, including deferred adjudication and expungements (unless a state expungement statute specifically forbids disclosure).
Example entry. DWI, Class B misdemeanor, Travis County Court at Law No. 4, Cause 11-987654, arrested 06/2011, deferred adjudication, completed 06/2013.
Nuance. Texas’s Government Code §411.0765 lets licensing agencies see sealed records, so do not rely on a non-disclosure order.
Common mistake and consequence. Filers omit a 20-year-old DWI thinking time has erased it; TDI surfaces it in fingerprint check and the omission is treated as fraud under Texas Insurance Code §4005.101.
Misconception. Traffic infractions below misdemeanor level do not need disclosure; misdemeanor traffic offenses (DWI, reckless driving) do.

Question 17: Regulatory and Administrative Actions

Plain English. Whether any regulator has investigated, fined, suspended, revoked, or denied a license to you.
How to answer. Provide the regulator, action type, date, case number, allegations, and disposition.
Example entry. Texas Department of Insurance, consent order, 12/2018, Order No. 18-1234, alleged late CE filing, $500 fine paid.
Nuance. “Investigated” includes informal inquiries and letters of caution, even when no formal action followed.
Common mistake and consequence. Filers omit FINRA letters of caution because no fine was imposed; FINRA’s BrokerCheck shows the letter, and TDI flags the omission.
Misconception. Settlements without admission of wrongdoing are not exempt from disclosure.

Question 18: License Denials, Suspensions, and Revocations

Plain English. Whether any license, charter, or registration has been denied, suspended, or revoked.
How to answer. Identify the license, jurisdiction, date, and grounds.
Example entry. None.
Nuance. A license that was simply allowed to lapse is not a revocation, but a license suspended pending CE compliance is.
Common mistake and consequence. Filers count voluntary surrender as “lapse,” but a surrender during pending investigation is treated as discipline.
Misconception. Out-of-country license revocations are not required; they are.

Question 19: Bond Refusal or Cancellation

Plain English. Whether a fidelity, surety, or errors-and-omissions bond has ever been declined, canceled, or non-renewed for you.
How to answer. Provide carrier, type of bond, date, and reason.
Example entry. None.
Nuance. Non-renewal at the carrier’s election counts; voluntary non-renewal by the insured does not.
Common mistake and consequence. Filers conceal a youthful E&O cancellation; the new carrier’s underwriting questions surface it later.
Misconception. Personal auto and homeowners cancellations are not required disclosures here; commercial bonds are.

Question 20: Investigations and Internal Reviews

Plain English. Whether you have been the subject of an internal corporate investigation involving alleged misconduct.
How to answer. Provide employer, dates, nature of allegation, and outcome.
Example entry. None.
Nuance. HR investigations into harassment, expense fraud, or trading violations all qualify even when concluded with no finding.
Common mistake and consequence. Filers think internal investigations are confidential; the affidavit specifically pierces internal confidentiality.
Misconception. Resignation during investigation does not erase the disclosure obligation.

Question 21: Other Material Information

Plain English. Anything else a regulator should know about your fitness.
How to answer. Disclose pending investigations, threatened litigation, deferred prosecution agreements, and reputational matters that could affect TDI’s view.
Example entry. None.
Nuance. When in doubt, disclose; the catch-all question is the most common source of after-the-fact misrepresentation findings.
Common mistake and consequence. Filers leave this blank when they should write None; blanks are treated as unanswered.
Misconception. “Material” is the regulator’s standard, not yours.

Authorization for Release of Information

Plain English. Your consent for TDI’s vendor to pull credit, criminal, regulatory, and employment records.
How to answer. Print your name, sign, date, and provide your Social Security number on the authorization page.
Example entry. Maria Elena Lopez-Hernandez / signature / 05/15/2026 / SSN xxx-xx-xxxx.
Nuance. The authorization must be wet-ink signed; electronic signatures are not yet accepted by every NAIC vendor.
Common mistake and consequence. Filers leave the SSN field blank for “privacy”; the vendor cannot run the check and the filing stalls.
Misconception. A separate corporate consent does not replace this individual authorization.

Notary Block (Jurat)

Plain English. The notary’s certification that you swore to the truth of the affidavit.
How to answer. Sign in front of the notary; the notary completes the jurat with state, county, date, expiration, and seal.
Example entry. Sworn to and subscribed before me on 05/15/2026 by Maria Elena Lopez-Hernandez, in Travis County, Texas. /s/ Janet Rivera, Notary, commission expires 03/01/2028.
Nuance. Remote online notarization is permitted in Texas under Government Code Chapter 406, but the resulting electronic notary certificate must be printed and submitted with the filing.
Common mistake and consequence. Notary stamps that are smudged or cut off at the page edge are routinely rejected by TDI’s intake.
Misconception. A notary acknowledgment is not the same as a jurat; the affidavit demands a jurat (“sworn to and subscribed”).

Fingerprint Card Attachment

Plain English. A fingerprint card or IdentoGO live-scan receipt accompanying the affidavit.
How to answer. Submit a completed FBI FD-258 card or a Texas DPS IdentoGO live scan receipt with service code provided by TDI.
Example entry. IdentoGO receipt #TX1234567, scan date 05/10/2026, service code 11G6QF.
Nuance. Out-of-state filers can submit FD-258 cards rolled by a local police department.
Common mistake and consequence. Filers send the receipt without the service code; without the code, DPS cannot route the results to TDI.
Misconception. A prior fingerprint on file with a securities regulator does not transfer to TDI.

Three Filled-Out Examples Using Real Scenarios

The three scenarios below show how typical filers complete Form NAIC-A from start to finish.

Scenario 1: Maria Lopez, New CFO of a Texas-Domestic Mutual Insurer

Form Section	What Maria Enters
Header	Lone Star Mutual Insurance Company / Texas / Primary Application
Q1 Full Name	Maria Elena Lopez-Hernandez
Q2 Other Names	Maria Elena Hernandez (1985–2009, maiden)
Q3 DOB / POB	03/14/1972, Monterrey, Nuevo León, Mexico
Q5 Residences	Three Texas addresses, 2014–present, no gaps
Q9 Employment	Big Three Reinsurance SVP, 2018–2024; Mid-Atlantic P&C VP, 2014–2018
Q13 Bankruptcy	None
Q16 Criminal	None
Q17 Regulatory	Texas DOI consent order 2018, $500 fine, late CE filing
Notary	Travis County, Texas, 05/15/2026

Scenario 2: Carlos Mendez, Out-of-State Director in a Form A Acquisition of a Texas Insurer

Form Section	What Carlos Enters
Header	Bayou Holdings Inc. / Texas / Form A
Q1 Full Name	Carlos Antonio Mendez
Q2 Other Names	None
Q3 DOB / POB	07/22/1965, Miami, Florida, USA
Q5 Residences	Florida and Connecticut addresses, 2016–present
Q9 Employment	Atlantic Capital Partners, Managing Director, 2010–present
Q11 Affiliations	Director of two Bermuda reinsurers and one Cayman captive
Q12 Stock Ownership	18% of Bayou Holdings common stock
Q15 Civil Litigation	Mendez v. Atlantic Re, S.D.N.Y., 2019, dismissed
Notary	Miami-Dade County, Florida, 05/12/2026

Scenario 3: Janet Wu, Officer of a New Texas HMO Applicant

Form Section	What Janet Enters
Header	Hill Country Health Plan, Inc. / Texas / Primary Application
Q1 Full Name	Janet Mei-Ling Wu
Q3 DOB / POB	11/02/1980, San Francisco, California, USA
Q5 Residences	California 2015–2022, Texas 2022–present
Q7 Designations	FSA, MAAA, both active
Q9 Employment	Pacific Health Plan, Chief Actuary, 2018–2024; Hill Country HP, COO, 2024–present
Q13 Bankruptcy	None
Q14 Liens	Satisfied California state tax lien, $3,200, 2017
Q17 Regulatory	None
Notary	Hays County, Texas, 05/14/2026

How to File the Completed Form

Texas accepts NAIC-A through three filing channels, and each requires a notarized wet-ink original even when the surrounding filing is electronic.

Mail (paper original). Send the original signed and notarized affidavit, the third-party background check report, the fingerprint receipt, and the resume to Texas Department of Insurance, Company Licensing and Registration, Mail Code CO-CLR, P.O. Box 149104, Austin, TX 78714-9104, or for courier delivery to 1601 Congress Avenue, Austin, TX 78701. There is no fee for the affidavit itself; fees attach to the parent filing (a Form A carries a $5,000 filing fee, a UCAA primary application carries a statutory examination deposit). Processing for the affidavit portion typically runs 30–60 days. Keep your USPS Certified Mail receipt or courier tracking number as your proof of filing.

Electronic UCAA submission. For UCAA expansion and corporate amendment filings, the affidavit is uploaded as a PDF exhibit through the NAIC’s electronic UCAA portal. The portal stores a timestamped receipt that serves as proof of filing. Background check vendor fees run roughly $250–$400 per affiant and are paid directly to the vendor.

In person. Walk-in delivery at the William P. Hobby Jr. State Office Building, 1601 Congress Avenue, Austin, is accepted during business hours; ask the front desk to date-stamp your transmittal letter for proof.

The third-party background check report is ordered separately by the affiant directly with Business Information Group or another NAIC-approved vendor, and the vendor delivers a sealed PDF directly to TDI under the affiant’s authorization. Allow 10–20 business days for the vendor to complete the report.

What Happens After You File

TDI’s Company Licensing section logs the filing, assigns a tracking number, and routes the affidavit to a financial analyst. The analyst reads every disclosure, compares it to the third-party background check, the fingerprint result, and any prior TDI files on the affiant. Discrepancies generate a deficiency letter, usually within 21 days, asking the affiant to clarify.

If the affidavit is clean and the underlying transaction (Form A, primary licensure, expansion) clears review, the affiant’s clearance is incorporated into TDI’s approval order. If TDI finds material misrepresentation, the regulator can deny the underlying transaction, refer the matter to enforcement, and notify other state regulators through the NAIC’s regulatory information sharing. A misrepresentation finding can also trigger a parallel referral to the affiant’s home-state insurance department and to FINRA or the SEC where applicable.

The six-month freshness clock means TDI can require a fresh affidavit if the parent transaction stalls past six months. Plan to refile if your deal is delayed; a stale affidavit is grounds for return without action under 28 TAC §7.205.

Mistakes to Avoid When Filling Out the Form

Leaving fields blank instead of writing N/A. TDI treats blanks as unanswered and returns the filing.
Using a nickname in Question 1. The background vendor cannot match nicknames to SSA records and reports “no record found.”
Omitting maiden or prior married names. Court records indexed under those names go undetected and surface later.
Skipping a brief gap in residence history. Even a 60-day gap triggers a clarification letter.
Reporting only “active” professional licenses. Lapsed licenses are required and must be flagged as lapsed.
Concealing a discharged bankruptcy. Lifetime disclosure is required; concealment is a separate violation.
Forgetting deferred adjudication on criminal records. Texas-deferred adjudication is reportable even when no conviction was entered.
Skipping FINRA letters of caution. Informal regulatory contacts count.
Using a notary acknowledgment instead of a jurat. The form demands a sworn jurat.
Submitting an affidavit older than six months. TDI returns it without review under the NAIC freshness rule.
Sending a smudged notary stamp. Intake rejects illegible seals.
Filing the same affidavit in multiple states. Each state needs a separate original with that state’s name in the header.

Do’s and Don’ts

Do’s

Do use Adobe Reader to fill the PDF, because Preview and browser PDFs strip field data.
Do match employment dates on the affidavit to your resume exactly; mismatches invite scrutiny.
Do disclose anything ambiguous; the catch-all in Question 21 is forgiving but blanks are not.
Do order the third-party background check the same day you sign the authorization, because vendor turnaround is the longest pole in the tent.
Do keep certified-mail or portal receipts; TDI will ask for filing-date proof if a deficiency arises.
Do update the affidavit if any answer changes during TDI review, because the duty to update runs through final approval.

Don’ts

Don’t rely on a Texas non-disclosure order to keep sealed records out of the affidavit; licensing agencies see them.
Don’t count voluntary license surrenders during investigation as “lapses.”
Don’t list a P.O. Box as your residence address.
Don’t sign the affidavit before the notary watches you sign; pre-signed jurats are void.
Don’t assume electronic signatures are accepted; the wet-ink original is still required.
Don’t treat the affidavit as a checkbox exercise; TDI’s analyst reads it line by line.

Pros and Cons of Filing on Your Own vs. With Help

Pros of filing on your own

You save the $1,500–$5,000 outside-counsel fee per affiant.
You control the timing without coordinating with an external advisor.
You learn the form, which helps in future filings.
You keep sensitive personal disclosures within a smaller circle.
You avoid the version-control problems of routing drafts back and forth.

Cons of filing on your own

You may miss the “informal regulatory inquiry” trap in Question 17.
You may misclassify a deferred adjudication as a non-conviction.
You may mis-handle the third-party background vendor authorization.
You may underestimate the six-month freshness clock and have to refile.
You bear personal exposure under Texas Insurance Code §4005.101 for any misrepresentation, even an honest mistake.

FAQs

Is Texas Form NAIC-A the same as the NAIC Biographical Affidavit (Form 11)?

Yes. TDI adopts the NAIC Form 11 by reference and calls it Form NAIC-A in its correspondence; the two refer to the same August 2022 PDF on the NAIC’s UCAA forms page.

Do I need to refile if my affidavit is more than six months old?

Yes. NAIC’s UCAA instructions require the affidavit to be dated within six months of TDI’s receipt date, and TDI returns stale affidavits without review.

Can I e-sign the affidavit?

No. Texas and the NAIC both still require a wet-ink original signature followed by a notary jurat; remote online notarization is acceptable if the certificate is printed.

Do I write my maiden name in Question 1 or Question 2?

No. Question 1 is your current legal name as on your Social Security card; Question 2 captures every prior name including maiden, anglicized, and prior married names.

Should I list a P.O. Box in Question 4?

No. Question 4 demands a physical residence address; list any P.O. Box separately as a mailing address only.

Do I disclose a deferred adjudication that never became a conviction?

Yes. Question 16 reaches every arrest, charge, indictment, and disposition, including deferred adjudication, regardless of whether a conviction was entered.

Do I need a separate affidavit for each state in a multi-state expansion?

Yes. The affidavit is jurisdictional, so each state’s filing needs its own original with that state’s name in the header.

Is a discharged bankruptcy from 20 years ago still reportable in Question 13?

Yes. The affidavit asks about lifetime bankruptcy history, and concealment is a separate violation under Texas Insurance Code §82.051.

Can my spouse’s stock count toward my Question 12 ownership disclosure?

Yes. Texas attributes spousal ownership for control determinations, so disclose spouse-held shares with a clear notation.

Do I list a FINRA letter of caution in Question 17?

Yes. Informal regulatory contacts and letters of caution count as regulatory actions for affidavit purposes, even when no fine attached.

Is the third-party background check report optional?

No. TDI requires the NAIC-approved vendor report alongside the affidavit; the affidavit alone does not satisfy the licensing requirement.

Can I use a notary acknowledgment instead of a jurat?

No. The affidavit is a sworn statement, so the notary must complete a jurat (“sworn to and subscribed before me”), not a simple acknowledgment.

Do I need to disclose foreign military service?

Yes. Question 10 covers any country’s armed forces, with branch, rank, dates, and discharge type.

Will TDI keep my Social Security number confidential?

Yes. TDI redacts Social Security numbers from the public file, but the rest of the affidavit can become public unless you obtain confidential treatment under Texas Insurance Code §823.011.

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