For the annual period ending:

Applicant's Name:
Business Entity Type (Ex: partnershiip, corporation, association, ect):
State of Domicile:
Address:
Phone Number:
Email Address:

Fiscal Year End Date:

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
• Current fee schedule of any applicable fee that could be charged to residents
• A current copy of the resident agreement and or admission package

Administrative Office:
Street Address:
City: State: Zip:
Phone: Fax: Email:

Continuing Care Facility:
Street Address:
City: State: Zip:
Phone:

CEO/Executive Director/Comparable Official:
Name:
Title:
Phone Number:

The undersigned certifies they have executed this application dated 12/06/2023 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.

Signature (Chief Executive Officer, Executive Director, or comparable official:
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.