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
•$25 fee will be paid upon submission
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 03/24/2023 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.
STATE OF KANSAS INSURANCE DEPARTMENT CONTINUING CARE PROVIDER ANNUAL DISCLOSURE STATEMENT This Disclosure Statement must be delivered to all prospective residents. This Disclosure Statement must be made available to current residents upon request. This disclosure must be made within 4 months of the end of your fiscal year every year and within 90 days of any ownership or management change to the provider or home. PART I - GENERAL DISCLOSURES Provider's Legal Name: Administrative Office: Street Address: City: State: Zip: Phone: Continuing Care Facility: Street Address: City: State: Zip: Phone: CEO/Executive Director/Comparable Official: Name: Title: Phone Number: Type of Provider: A. Defined Voluntary B. For Profit Not for Profit C. Corporation Partner Individual Other: Entrance fee: Periodic fee: per: PART II - ITEMIZED DISCLOSURES Please read each item below, check the appropriate answer and provide the necessary documentation as requested by email to kid.addah@ks.gov Incomplete applications cannot be processed. Provider is individually owned. Please provide as "Exhibit A" the name(s) of any individual(s) who constitute the provider. Provider is not individually owned. Provider is a corporation, partnership or other legal entity. Please provide as "Exhibit B" thenames of the officers, directors, trustees, managing or general partners of the provider. Provider is not a corporation, partnership or other legal entity. Provider is a corporation. Please provide "Exhibit C" the name(s) of any individual(s) who own(s) 10% or more of the stock of such corporation. Provider is not a corporation or, if a corporation, no individual owns10% or more of such corporation.. Check here if any officer director or owner of provier has been convicted of any crime or been a party to any civil action claiming fraud, enbezzlement, fraudulent conversion or misappropriation of property, which resulted in a judgment against such person(s) Please provide "Exhibit D" the name(s) of such person(s). There are no convictions or judgments against officials, directors or owners. Check here if any person(s) has/have had any state or federal license or permit related to care and housing suspended or revoked. Please provide as "Exhibit E" the name(s) of any person(s) who has/have had any state or federal license or permit related to care and housing suspended or revoked. No suspensions or revocation. Provider/Manager has experience in the operation of homes providing continuing care. Please provide as "Exhibit F" a statement of the years of experience of the provider and/or manager in the operation of homes providing continuing care. Provider/Manager has no experience. Provider is not incorporated or operated on a for-profit basis. Please provide as "Exhibit G" the name(s) and business address(es) of any individual(s) having any ownership or beneficial interest in the provider and a description of such interest in or occupation with the provider. Provider is incorporated and not for profit. Provider is affiliated with a religious, charitable or non-profit organization. Please provide as "Exhibit H" as a statement identifying any religious, charitable or non-profit organization with which the provider is affiliated and the extent of that affiliation. Include in the exhibit any information regarding the extent to which an affiliated organization will be responsible for the financial and contractual obligations of the provider. Provider is unaffiliated. Provider (or its affilaited, if any) is/are exempt from the payment of Federal income tax under Section of the Internal Revenue Code. Provider is not exempt from Federal income tax. Provider is exempt from local property tax. Provider is not exempt from local property tax. PART III - ANNUAL AUDIT Important information PLEASE READ: The continuing care provider is required to have an annual certified audit prepared by a Certified Public Accountant and to provide a copy of the audit to the Kansas Insurance Department by email to kid.addah@ks.gov A copy of this audit must be made available to any resident or perspective resident upon request. This disclosure statement, and the information contained herein and provide hereto, is true and correct to the best of my knowledge. Signature of CEO or Executive Director: 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. CONTINUING CARE PROVIDER PRE-OPERATIONAL ADDENDUM Pursuant to K.S.A. 40-2232(f) the following information is required for Continuing Care Providers who have received contract considerations but has not yet commenced operation of a home or facility. Name of Continue Care Provider: 1) A statement of the anticipated source and application of the funds used or to be used in the purchase or construction of the facility: 2) An estimate of such costs as financing expense, legal expense, land costs, marketing costs and other similar costs which the provider expects to incur or become obligated for prior to the commencement of operations: 3) A description of any mortage loan or any other financing intended to be used for the financing of the facility, including the anticipated terms and costs of such financing: 4) An estimate of the total entrance fee to be received from or on behalf of resident at or prior to commencement of operation; and 5) An estimate of the funds, if any, which are anticipated to be necessary to fund start-up loses and provide reserve funds to assure full performance of the obligations of the provider under continuing care contracts. Acknowledged by: Name: Title: Phone: Email:
