Fillable Financial Affairs Division Arizona Department of Insurance 100 (Arizona)

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Financial Affairs Division Arizona Department of Insurance 100 (Arizona)

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Form E-SR.REG (v 20180619) Page 1 of 4
Financial Affairs Division
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 102, Phoenix, Arizona 85007-2624
Phone: (602) 364-3986
Web: https://insurance.az.gov
SENIOR RESIDENTIAL ENTRANCE FEE CONTRACTS: PROVIDER REGISTRATION
ARIZONA REVISED STATUTES TITLE 44, CHAPTER 25, ARTICLE 1
REGISTRATION INSTRUCTIONS:
1. Enter complete Provider Registrant Information below, including the Month and Day of its Fiscal Year End.
2. Photocopy a sufficient supply of Pages 2, 3 and 4, as needed to provide all required information for each Schedule.
3. Attach a complete copy of the Provider’s most recent Audited Financial Report.
4. Attach a complete photocopy of the Disclosure Statement that is currently in use in accordance with
A.R.S. § 44-6954(D)(2).
5. Remit the Registration Fee specified below in the form of a check payable to the Arizona Department of Insurance.
6. Complete and execute the Certification and Signature section below.
7. Submit all of the above together, with the check stapled to the upper-left corner of this page.
PROVIDER REGISTRANT INFORMATION:
PLEASE PRINT CLEARLY OR TYPE
Full and Exact Provider Name:
Business Address:
Mail Address:
Telephone Number:
Facsimile (FAX) Number:
FISCAL YEAR END
Registration Fee Due (Make check payable to Arizona Department of Insurance)
$250.00
CERTIFICATION AND SIGNATURE:
The undersigned Preparer certifies that he/she is duly authorized to execute this registration statement and that the information
provided is true and correct to the best of his/her knowledge and belief. Preparer acknowledges on the Provider’s behalf that the
Provider must file any amendments to its Disclosure Statement with the Arizona Department of Insurance within 14 days
after making the amendment.
Type or Print Preparer’s Name and Title
Preparer’s Signature and Date Signed
MAIL THIS REGISTRATION AND RELATED CORRESPONDENCE TO:
Arizona Department of Insurance
Financial Affairs Division
100 North 15
th
Avenue, Suite 102
Phoenix, AZ 85007-2624
Reset
SENIOR RESIDENTIAL ENTRANCE FEE CONTRACTS: PROVIDER REGISTRATION
ARIZONA REVISED STATUTES TITLE 44, CHAPTER 25, ARTICLE 1
Form E-SR.REG (v 20180619) Page 2 of 4
SCHEDULE 1
PROVIDE THE NAME, BUSINESS ADDRESS AND BUSINESS TELEPHONE NUMBER OF EACH PERSON HOLDING AT
LEAST A TEN PER CENT (10%) OWNERSHIP INTEREST IN THE PROVIDER.
Name:
Business Address:
City: State: Zip Code:
Telephone Number: ________________________________________________________________________________________
Name:
Business Address:
City: State: Zip Code:
Telephone Number: ________________________________________________________________________________________
Name:
Business Address:
City: State: Zip Code:
Telephone Number: ________________________________________________________________________________________
Name:
Business Address:
City: State: Zip Code:
Telephone Number: ________________________________________________________________________________________
Name:
Business Address:
City: State: Zip Code:
Telephone Number: ________________________________________________________________________________________
Name:
Business Address:
City: State: Zip Code:
Telephone Number: ________________________________________________________________________________________
Name:
Business Address:
City: State: Zip Code:
Telephone Number: ________________________________________________________________________________________
SENIOR RESIDENTIAL ENTRANCE FEE CONTRACTS: PROVIDER REGISTRATION
ARIZONA REVISED STATUTES TITLE 44, CHAPTER 25, ARTICLE 1
Form E-SR.REG (v 20180619) Page 3 of 4
SCHEDULE 2
PROVIDE MAILING AND STREET ADDRESSES FOR EACH OF THE PROVIDER’S FACILITIES:
Facility Name:
Mailing:
City: State: Zip Code:
Street:
City: State: Zip Code:
Facility Name:
Mailing:
City: State: Zip Code:
Street:
City: State: Zip Code:
Facility Name:
Mailing:
City: State: Zip Code:
Street:
City: State: Zip Code:
Facility Name:
Mailing:
City: State: Zip Code:
Street:
City: State: Zip Code:
SENIOR RESIDENTIAL ENTRANCE FEE CONTRACTS: PROVIDER REGISTRATION
ARIZONA REVISED STATUTES TITLE 44, CHAPTER 25, ARTICLE 1
Form E-SR.REG (v 20180619) Page 4 of 4
SCHEDULE 3
PROVIDE THE NAME, BUSINESS ADDRESS AND BUSINESS TELEPHONE NUMBER OF THE CHIEF ADMINISTRATOR FOR
EACH FACILITY LISTED IN SCHEDULE 2.
Facility Name:
Chief Administrator Name:
Business Address:
City: State: Zip Code:
Telephone Number: ________________________________________________________________________________________
Facility Name:
Chief Administrator Name:
Business Address:
City: State: Zip Code:
Telephone Number: ________________________________________________________________________________________
Facility Name:
Chief Administrator Name:
Business Address:
City: State: Zip Code:
Telephone Number: ________________________________________________________________________________________
Facility Name:
Chief Administrator Name:
Business Address:
City: State: Zip Code:
Telephone Number: ________________________________________________________________________________________
Facility Name:
Chief Administrator Name:
Business Address:
City: State: Zip Code:
Telephone Number: ________________________________________________________________________________________
Facility Name:
Chief Administrator Name:
Business Address:
City: State: Zip Code:
Telephone Number: ________________________________________________________________________________________
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Financial Affairs Division Arizona Department of Insurance 100 (Arizona)

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Completed 12 August 2020

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