APPLICATION FOR NEW CONTINUING CARE PROVIDER CERTIFICATE OF REGISTRATION








If there is a change of ownership, or management of the provider or home, the new owners must file all required documents within 90 days of change.

Applicant hereby submits this application and supporting documents for a CERTIFICATE OF REGISTRATION pursuant to K.S.A. 40-2231 through K.S.A. 40-2238, authorizing the above-named continuing care provider to operate or continue to operate in the State of Kansas until such certificate is suspended, revoked, or terminated by the Insurance Commissioner of Kansas. Applicant hereby certifies the continuing care provider making this application is in compliance with the requirements of K.S.A. 40-2231 through K.S.A. 40-2238.

Emailed to kid.addah@ks.gov for this application are:

•CPA certified annual audit of most recent fiscal year and copies of anycontinuing care contract forms. The CPA audit must be filed with the Commissioner within 4 months of completion of such provider’s fiscal year.

•Annual Disclosure Statement

•Certification

•$50 fee will be paid upon submission


Administrative Office:




Continuing Care Facility:




CEO/Executive Director/Comparable Official:




The undersigned certifies they have executed this application dated 11/30/2022 for and on behalf of , that they are a duly appointed representative of such provider, that they are authorized to execute and file this application, and that the information contained in this application is true and accurate to the best of their knowledge.


By typing your name above, you are signing this electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.