"Continuing Care Provider Annual Disclosure Statement" - Kansas

Continuing Care Provider Annual Disclosure Statement is a legal document that was released by the Kansas Insurance Department - a government authority operating within Kansas.

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STATE OF KANSAS
INSURANCE DEPARTMENT
CONTINUING CARE PROVIDER
ANNUAL DISCLOSURE STATEMENT
This Disclosure Statement must be delivered to all prospective residents. This Disclosure
Statement must be made available to current residents upon request.
PART I – GENERAL DISCLOSURES
A. Provider: _______________________________________________________________
B. Administrative
Office:
_______________________________________
(Street Address)
_______________________________________
(City)
(State)
(Zip)
_______________________________________
(Phone)
C. Continuing Care
Facility:
_______________________________________
(Street Address)
_______________________________________
(City)
(State)
(Zip)
_______________________________________
(Phone)
D. Chief Executive Officer
Executive Director:
_______________________________________
(Name)
_______________________________________
(Title)
_______________________________________
(Phone)
STATE OF KANSAS
INSURANCE DEPARTMENT
CONTINUING CARE PROVIDER
ANNUAL DISCLOSURE STATEMENT
This Disclosure Statement must be delivered to all prospective residents. This Disclosure
Statement must be made available to current residents upon request.
PART I – GENERAL DISCLOSURES
A. Provider: _______________________________________________________________
B. Administrative
Office:
_______________________________________
(Street Address)
_______________________________________
(City)
(State)
(Zip)
_______________________________________
(Phone)
C. Continuing Care
Facility:
_______________________________________
(Street Address)
_______________________________________
(City)
(State)
(Zip)
_______________________________________
(Phone)
D. Chief Executive Officer
Executive Director:
_______________________________________
(Name)
_______________________________________
(Title)
_______________________________________
(Phone)
E. Type of Provider:
1. ______ Defined
______ Voluntary
2. ______ For Profit
______ Not-for-Profit
3. ______ Corporation
______ Partnership
______ Individual
______ Other: ________________________________________
4. Entrance fee:
$_______________________
5. Periodic fee:
$_______________________ per _______________________
PART II – ITEMIZED DISCLOSURES
Please read each item below, check the appropriate answer and provide the
necessary documentation as requested. Incomplete applications cannot be
processed and will be returned.
A. _____Provider is individually owned. Please attach as “Exhibit A” the name(s) of any
individual(s) who constitute the provider.
_____ Provider is not individually owned.
B. _____Provider is a corporation, partnership or other legal entity. Please attach as
“Exhibit B” the names of the officers, directors, trustees, managing or general partners of
the provider.
_____ Provider is not a corporation, partnership or other legal entity.
C. _____Provider is a corporation. Please attach as “Exhibit C” the name(s) of any
individual(s) who own(s) 10% or more of the stock of such corporation.
_____Provider is not a corporation or, if a corporation, no individual owns 10% or more
of such corporation.
D. _____Check here if any officer, director or owner of provider has been convicted of any
crime or been a party to any civil action claiming fraud, embezzlement, fraudulent
conversion or misappropriation of property, which resulted in a judgment against such
person(s). Please attach as “Exhibit D” the name(s) of such person(s).
_____ There are no convictions or judgments against officials, directors or owners.
E. _____Check here if any person(s) has/have had any state or federal license or permit
related to care and housing suspended or revoked. Please attach as “Exhibit E” the
name(s) of any person(s) who has/have had any state or federal license or permit related
to care and housing suspended or revoked.
_____ No suspensions or revocations.
F. _____Provider/Manager has experience in the operation of homes providing continuing
care. Please attach as “Exhibit F” a statement of the years of experience of the provider
and/or manager in the operation of homes providing continuing care.
_____ Provider/Manager has no experience.
G. _____Provider is operated on a for-profit basis. Please attach as “Exhibit G” the name(s)
and business address(es) of any individual(s) having any ownership or beneficial interest
in the provider and a description of such interest in or occupation with the provider.
_____Provider is not for profit.
H. _____Provider is affiliated with a religious, charitable or non- profit organization. Please
attach as “Exhibit H” a statement identifying any religious, charitable or non-profit
organization with which the provider is affiliated and the extent of that affiliation.
Include in the exhibit any information regarding the extent to which an affiliated
organization will be responsible for the financial and contractual obligations of the
provider.
_____ Provider is unaffiliated.
I.
_____Provider (or its affiliates, if any) is/are exempt from the payment of Federal
income tax under Section _____ of the Internal Revenue Code.
_____ Provider is not exempt from Federal income tax.
J.
_____Provider is exempt from local property tax.
_____Provider is not exempt from local property tax.
PART III – ANNUAL AUDIT
Important information PLEASE READ:
The continuing care provider is required to have an annual certified audit prepared by a
Certified Public Accountant and to provide a copy of the audit to the Kansas
Insurance Department.
A copy of this audit must be made available to any resident or perspective resident upon
request.
This disclosure statement, and the information contained herein and attached hereto, is
true and correct to the best of my knowledge.
_________________________________
Signature of CEO or Executive Director
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