Ccrc Form 4 – Fill Out and Use This PDF

6.Member of Professional Societies or Associations: (List)

7.Present or Proposed Position with Applicant:

How long with this CCRC?

8.Complete Employment Record for Past 20 years: include jobs, positions, directorates or officerships.

11.Are there any transactions anticipated between any sole proprietorship, partnership or corporation and

14.Have you ever been indicted or convicted for embezzlement, theft or larceny, mail fraud, or for any other

criminal offense, or for violating any corporate securities statute or any insurance law, or have you been

the subject of a cease and desist order of any federal or state securities regulatory agency? If so, please explain in full detail.

15.Have you ever been refused a professional, occupational or vocational license by any public or

16.Have you ever been in any way connected with, or financially interested in, any CCRC or

insurance company which became insolvent or was placed under supervision or in receivership or

conservatorship while you were affiliated with it or at any time thereafter? If so, please explain in detail.

20.Have you ever been denied an individual or position schedule fidelity bond, or had a bond cancelled or

21.Have you ever been connected in any way with a CCRC or insurance company which was placed under a

22.Have you ever been connected in any way with any sole proprietorship, partnership, corporation or other

entity which has been cited for violations or was subject to disciplinary action by any state or federal

I FULLY UNDERSTAND THAT THE INFORMATION HEREINBEFORE FURNISHED IN SUBJECT TO THE PENALTIES PROVIDED BY ARTICLE 21.47 OF THE TEXAS INSURANCE CODE.

Dated

(Signature)

INCOMPLETE APPLICATIONS IMPEDE TIMELY REVIEW BY THE DEPARTMENT; THEREFORE, IT IS EXTREMELY IMPORTANT THAT APPLICATIONS ARE COMPLETE. Submit a complete filing to the Texas Department of Insurance, Company Licensing & Registration, MC 305-2C, P. O. Box 149104, Austin, TX 78714-9104. For questions or more information, call (512) 322-4370.

THESE GUIDELINES ARE GENERAL IN NATURE AND DO NOT SUPERCEDE STATUTE OR REGULATION. THEY ARE NOT INTENDED TO BE ALL INCLUSIVE AND ADDITIONAL DOCUMENTATION MAY BE REQUESTED.

CONTINUING CARE RETIREMENT COMMUNITY (CCRC)

INSTRUCTIONS FOR COMPLETION

OF BIOGRAPHICAL DATA FORMS

MINIMUM REQUIREMENT FOR SUBMISSION OF BIOGRAPHICAL DATA FORMS APPLIES TO ALL PERSONS WHO ARE OFFICERS, DIRECTORS, TRUSTEES, MANAGING OR GENERAL PARTNER. ANY PERSON WHO HAS AT LEAST 10% INTEREST IN THE PROVIDER OR ANY PERSON ENGAGED IN THE DAY-TO-DAY MANAGEMENT OF THE FACILITY OTHER THAN AN INDIVIDUAL DIRECTLY EMPLOYED BY THE PROVIDER.

The attached biographical data form may be reproduced in any such quantity as is required for future use by the company. Completed biographical data forms and attachments for submission are required on letter size paper only (8 ½” x 11”).

Each biographical data form must contain an original signature (photo or xerox copies of the original are not acceptable). Full disclosure of more than one position with all companies with which the individual is associated must be indicated. The individual's position with the facility should appear in answer to either question #7 or question #8.

Each company is responsible for reviewing the completeness of the biographical data forms prior to submission to the Texas Department of Insurance.

Notice of any additions, deletions, and modifications to the officers and directors page (CCRC Form #3) must be given in accordance with §33.511 of the CCRC Rules.

NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES. With few exceptions, you are entitled to be informed about the information that the Texas Department of Insurance (TDI) collects about you. Under sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or receive copies of information about yourself, including private information. However, TDI may withhold information for reasons other than to protect your right to privacy. Under section 559.004 of the Texas Government Code, you are entitled to request that TDI correct information that TDI has about you that is incorrect. For more information about the procedure and costs for obtaining information from TDI or about the procedure for correcting information kept by TDI, please contact the Agency Counsel Section of TDI’s Legal & Compliance Division at (512) 475-1757 or visit the Corrections Procedure section of TDI’s web page at www.tdi.texas.gov.