Fillable LIFE CARE PROVIDER ANNUAL REPORT ARS 20-1807 (Arizona)

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LIFE CARE PROVIDER ANNUAL REPORT ARS 20-1807 (Arizona)

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E-LIFECARE (v 20211201) Page 1 of 12
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):
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 My Commission Expires
Stamp or Seal here
Type/Print Preparer's Name and Title Preparer’s Phone Number and E-Mail Address
Send the Annual Report filing to financialfilings@difi.az.gov. Do not also send a hard copy filing.
Make the $450.00 payment through OPTins (ARIZONA APPLICATION/RENEWAL FEES) https://www.optins.org/
(there is a $15.00 transaction fee) or mail check made payable to the Arizona Department of Insurance and
Financial Institutions along with a cover letter to: Insurance Financial Affairs Division
Arizona Department of Insurance and Financial Institutions
100 N. 15th Ave., Suite 261
Phoenix, Arizona 85007-2630
Reset
E-LIFECARE (v 20211201) Page 2 of 12
1. State the name, the address and a description of the physical property of the facility below.
E-LIFECARE (v 20211201) 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 20211201) 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 20211201) 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 20211201) 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 20211201) 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 20211201) 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 20211201) 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 20211201) 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 20211201) 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 20211201) 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 and Financial Institutions 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 and Financial Institutions. 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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LIFE CARE PROVIDER ANNUAL REPORT ARS 20-1807 (Arizona)

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Completed 1 July 2022

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