Form E654 (v 20180619)
Financial Affairs Division
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 102, Phoenix, Arizona 85007-2624
Phone: (602) 364-3999
Web: https://insurance.az.gov
APPLICATION FOR LIFE CARE PROVIDER PERMIT CHANGE
Provider Name Employer’s ID Number
State of Domicile , Date Incorporated/Organized , Type of Entity
Home Office ,
(Street and Number) (City, State and Zip Code)
,
(Telephone Number) (Fax Number)
Administrative/Mail ,
(Street and Number) (City, State and Zip Code)
,
(Post Office Box) (City, State and Zip Code)
,
(Telephone Number) (Fax Number)
Facility Name
Facility Address ,
(Street and Number) (City, State and Zip Code)
Number of:
(Living Units) (Assisted Living Units) (Health Care Beds) (Contract Holders)
Contact Person ,
(Name) (Title)
,
(Telephone Number) (Email Address)
Provider hereby applies for an amended Permit in accordance with the provisions of Arizona Revised Statutes, Title 20, Chapter 8, Article
1 due to change of the Provider’s .
As a condition precedent to and as a consideration for the issuance of the Permit to enter into life care contracts herein applied for, this
Provider declares that it has complied with all laws of the state of domicile relating to such companies, and that it accepts the terms and
provisions of the laws of the State of Arizona applicable to said Provider.
I certify that I have reviewed this Application. It is true, complete and correct to the best of my knowledge and belief.
Dated at this day of ,
Signature of Chief Executive Officer Title
