Fillable LIFE CARE PROVIDER ANNUAL REPORT AMENDMENT (Arizona)

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LIFE CARE PROVIDER ANNUAL REPORT AMENDMENT (Arizona)

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E-LIFECARE.AMEND (v. 20181218)
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 AMENDMENT
FOR THE FISCAL YEAR ENDING:
AMENDMENT DATE:
(Full and Exact Corporate Name)
OF:
(Doing Business As / Or Facility 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 – enter phone numbers below)
Phone No.:
( )
Toll-Free:
( )
Fax No.:
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 information and Exhibits 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 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
Preparer's Name and Title Preparer’s Phone Number and E-Mail Address
THERE IS NO FILING FEE REQUIRED FOR THIS AMENDMENT REPORT
MAIL THIS REPORT TO the address shown above.
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LIFE CARE PROVIDER ANNUAL REPORT AMENDMENT (Arizona)

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Completed 12 August 2020

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