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

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Financial Affairs Division Arizona Department of Insurance LIFE (Arizona)

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E-LIFECARE (v. 20191104) Page 1 of 12
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/
LIFE CARE PROVIDER ANNUAL REPORT – ARS § 20-1807
Enter the YEAR for this report below and the Due Date YEAR will appear:
FISCAL YEAR END
Month / Day
YEAR of
this Report
REPORT DUE
DATE
Month / Day
YEAR
due
February 28

May 29
June 30

September 28
October 31

January 29
December 31

March 31
(Full and Exact Provider Name)
(Statutory Home Office Address: Street & Number, City, State, Zip Code and phone number)
(Administrative Office Address: Street & Number, P.O. Box, City, State, Zip Code)
Phone No.:
( )
Toll-Free:
Fax No.:
( )
(Doing Business As / Facility Name)
(Facility Address: Street & Number, City, State, Zip Code and phone number)
NAIC No.(if assigned):
Arizona Company No. (if assigned):
Fed. ID No.:
organized under the laws of
on
(Month, Day, Year)
as a Non-Profit Corporation Stock Company Partnership
Other (Specify):
hereby submits the attached sixteen (16) items of information and Exhibits thereto, in accordance with ARS §
20-1807.
Dated at
, this
day of
,
20
I hereby depose and certify that I have prepared or reviewed this Report and it is true, complete, and correct to
the best of my knowledge and belief.
Signature of Chief Executive Officer ONLY Type/Print Chief Executive Officer’s Name and Title
Subscribed and sworn to before me, this
day of
,
20
Notary Signature Stamp or Seal here My Commission Expires
Type/Print Preparer's Name and Title Preparer’s Phone Number and E-Mail Address
THE FILING FEE REQUIRED TO BE SENT WITH THIS REPORT IS $450.00. Make check
payable to the ARIZONA DEPARTMENT OF INSURANCE.
Send the check with the Life Care Provider Annual Report to the attention of the Financial
Affairs Division at the address shown above.
Reset
E-LIFECARE (v. 20191104) Page 2 of 12
1. State the name, the address and a description of the physical property of the facility
below.
E-LIFECARE (v. 20191104) Page 3 of 12
2. a. Make a written statement below of the terms and conditions of the life care contracts
to be used by the Provider, including the services to be provided to residents pursuant
to the contract and the fees or charges to be paid by residents, including the method of
payment of the fees or charges.
The life care contract shall provide that any person entering into the contract shall have
a period of seven days within which to rescind the life care contract without penalty or
further obligation beginning with the first full calendar day following the last to occur of:
the execution of the contract, the payment of an initial sum of money as a deposit or
application fee, receipt of a copy of the Provider's most recent annual report if the
Provider has filed an annual report with the Director of Insurance pursuant to A.R.S. §
20-1807, or, if the Provider has not filed an annual report, a copy of the Provider’s
application. In the event of a rescission, all money or property paid or transferred by the
person shall be fully refunded by the Provider. A person shall not be required to move
into a facility until after the expiration of the seven-day rescission period.
b. Attach a copy of the Life Care Contract as Exhibit 1.
E-LIFECARE (v. 20191104) Page 4 of 12
3. If the Provider is not an individual, such as a corporation, partnership or trust, make a
written statement below naming the fiscal year end date that is the last day of a calendar
month and the type of legal entity and listing the interest and extent of such interest of each
principal in the entity.
4. a. If the Provider is not an individual, list below the names of all members of the Board
of Directors, Officers, Trustees, or Managing Partners.
b. Attach, as Exhibit 2, the executed NAIC UCAA Biographical Affidavit Form 11 for
EACH person that has not filed a Biographical Affidavit within the previous 3-year
period. A Biographical Affidavit is required immediately on the substitution or
installation of a member of the board of directors or an officer, trustee or managing
partner different from the information disclosed in the Provider’s application. The
NAIC UCAA Biographical Affidavit Form 11 is located at https://www.naic.org/
industry_ucaa.htm. Please make sufficient supply to distribute to all persons
required to file at this time or in the near future. Each Affidavit must be complete for
all information requested, and must be signed and notarized. Incomplete or
improperly executed Affidavits are not acceptable.
NAME
TITLE
DATE BIOGRAPHICAL
AFFIDAVIT WAS LAST FILED
E-LIFECARE (v. 20191104) Page 5 of 12
5. (a) The number of residents of the facility to be provided services by the Provider
pursuant to the life care contracts.
Number on last day of reporting fiscal year
Estimate number on following fiscal year end
(b) The number of living units occupied pursuant to the life care contracts.
Number on last day of reporting fiscal year
Estimate number on following fiscal year end
(c) The number of residents of the facility to be provided services by the Provider under
contracts other than life care.
Number on last day of reporting fiscal year
Estimate number on following fiscal year end
(d) The number of living units occupied pursuant to contracts other than life care.
Number on last day of reporting fiscal year
Estimate number on following fiscal year end
E-LIFECARE (v. 20191104) Page 6 of 12
6. Make a written statement below of the provisions that have been made or will be made
to provide reserve funding or security by the Provider to enable the Provider to fully
perform the Provider’s obligations pursuant to life care contracts, including the
establishment of escrow accounts, accounts in financial institutions, trusts or reserve
funds.
E-LIFECARE (v. 20191104) Page 7 of 12
7. Make a written statement below as to whether the Provider was or is affiliated with a
religious, charitable or other nonprofit organization, the extent of any affiliation and the
extent to which the affiliate organization will be responsible for the financial and contract
obligations of the Provider.
8. If the Provider is a subsidiary corporation or the affiliate of another corporation, make a
written statement below identifying the Parent Corporation or the other Affiliate
Corporation and the primary activities of the parent or other affiliate corporation.
E-LIFECARE (v. 20191104) Page 8 of 12
9. Provide a written description below of the business experience of the Provider in the
operation of similar facilities and, if the facility will be managed on a day-to-day basis by
a corporation or organization other than the Provider, a description of the business
experience of the manager in the operation or management of similar facilities.
10. Make a written statement below as to whether the Provider, a promoter, a principal, a
parent or subsidiary corporation, or an affiliate has had any injunctive or restrictive order
of a court of record, or any suspension or revocation of any state or federal license or
permit, arising out of or relating to business activity or health care applied against it,
including without limitation actions affecting a license to operate a foster care facility, a
health care institution, a retirement home, or a home for the aged.
E-LIFECARE (v. 20191104) Page 9 of 12
11. Make a written statement below of any periodic rates to be initially paid by the
residents, the method by which the rates are determined and the manner by which the
Provider may adjust the rates in the future. If the facility is already in operation, or if the
Provider operates one or more similar facilities within this state, the statement must
include tables showing the frequency and average dollar amount of each increase in
periodic rates at each facility for the previous five years or any shorter period as the
facility may have been operated by the Provider.
E-LIFECARE (v. 20191104) Page 10 of 12
12. Make a written statement below of the terms and conditions under which a life care
contract may be canceled by the Provider or Resident, including any health and financial
conditions required for a person to continue as a resident and any conditions under
which all or any portion of the entrance fee will be refunded by the Provider.
E-LIFECARE (v. 20191104) Page 11 of 12
13. If construction or purchase of the facility has not yet been completed, make a written
statement below of the anticipated source and application of the monies (in financial
statement form) to be used in the purchase or construction, including all of the following:
(a) An estimate of the cost of purchasing or constructing and equipping the facility
including related costs as financing expense, legal expense, land costs,
occupancy development costs and all other similar costs that the Provider
expects to incur or become obligated for before the commencement of
operations.
(b) An estimate of the total entrance fees to be received from residents on completion
of occupancy.
(c) A description of any mortgage loan or other long-term financing intended to be
used for the financing of the facility, including the anticipated terms and costs of
the financing.
(d) An estimate of any funds that are anticipated to be necessary to fund start-up
losses and to assure full performance of the obligations of the Provider pursuant
to life care contracts including any reserve fund escrow required by the Director
pursuant to ARS § 20-1806.
E-LIFECARE (v. 20191104) Page 12 of 12
14. Attach as Exhibit 3, certified financial statements of the Provider, Promoter and
Manager as of a date not more than ninety (90) days before the date the Annual
Report is filed, that shall include a balance sheet and the related statements of
income, retained earnings or equity and changes in financial position for the two
most recent fiscal years or any shorter period of time as the Provider, Promoter or
Manager has been in existence. Each of these statements shall be prepared in
accordance with generally accepted accounting principles and reported on by a
certified public accountant in accordance with generally accepted auditing standards.
The certified financial statements of the Promoter shall be filed with the Annual Report
unless the Promoter is not currently employed by the Provider.
Assets shall be reported at values determined pursuant to ARS §§ 20-511 through 20-
515. If the Director of Insurance deems it necessary to value any real estate, the
Director may employ one or more competent appraisers for that purpose and the
reasonable expense thereof shall be borne by the Provider.
15. Attach as Exhibit 4, an actuarial study prepared by a qualified actuary for the purpose
of demonstrating that the project has sufficient revenues and funds, including reserves,
for the project to continue as a viable operating concern. The actuarial study shall
include a cash flow projection, an evaluation of the adequacy of current pricing
structures and an analysis of the long-term relationship between the project's assets
and liabilities. The Provider shall file the actuarial study on a triennial basis beginning
with the year in which resident occupancy began at the facility pursuant to the permit
issued to the Provider, or more often as required by the Director of Insurance. If an
actuarial study is not filed with this Annual Report, state the date of the last filed actuarial
study.
16. Attach as Exhibit 5, copies of the escrow agreements executed with an escrow agent
pursuant to ARS §§ 20-1804 and 20-1806.
WE MAY ASSESS AND COLLECT A CIVIL PENALTY OF NOT MORE THAN $25 FOR
EACH DAY THAT YOUR ANNUAL REPORT IS LATE IF YOU FAIL TO TIMELY FILE YOUR
ANNUAL REPORT OR PAY THE REQUIRED FILING FEE. ARS § 20-1807(F).
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Financial Affairs Division Arizona Department of Insurance LIFE (Arizona)

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Completed 12 August 2020

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