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/
E-LIFECARE.AS (v. 20191104)
Life Care Provider Annual Report Filing Checklist
Attach this Checklist on top of your Annual Report Form E-LIFECARE
E
nter the information for the Life Care Provider and Manager (if applicable) below:
Month/Day
Month/Day
Financial Statement “As of” Date
Completed
& Enclosed
Initial at left if items are included with Annual Report Form E-LIFECARE
Use Only
A. $450.00 Filing Fee - A check payable to Arizona Department of Insurance is
enclosed.
B. Title Page (Page 1 of 12) is complete for all information.
C. Chief Executive Officer - Name, Title and Signature on Page 1.
D. Notarization of Chief Executive Officer Signature on Page 1.
E. Preparer’s Name, Title, Phone and Email address on Page 1.
F. Pages 2 through 11 - Complete responses to Items 1 through 13.
G. Page 3, Exhibit 1 - Copy of Life Care Contract.
H. Page 4, Exhibit 2 - NAIC UCAA Biographical Affidavit Form 11 for each officer,
director, trustee or managing partner that has not filed a biographical affidavit
within the last 3 years. **Enter “N/A” in box if all biographical affidavits have been
filed within the last 3 years
→
I. Page 12, Exhibit 3 - Certified Financial Statement(s) for the 2 most recent fiscal
years of the:
1. Provider…………………………………………………………………………………...
2. Manager, if applicable. **Enter “N/A” in box if not applicable →
3. Promoter, if applicable. **Enter “N/A” in box if not applicable→
J. Page 12, Exhibit 4 - Actuarial Study, if applicable. **Enter date last filed if not
enclosed
K. Page 12, Exhibit 5 - Copies of escrow agreements.
