What Is CCRC Form 4?
CCRC Form 4 is the Biographical Data Form used by the Texas Department of Insurance Financial Regulation Division. The form is part of the licensing and application process for Continuing Care Retirement Communities in Texas. It ensures that people in leadership roles at a CCRC meet the state's standards for professional conduct and ethical operation.
Who Needs to Complete This Form?
You must complete CCRC Form 4 if you hold any of these roles at a Texas CCRC:
- Officer, director, or trustee of the CCRC provider
- Managing or general partner of the community
- Anyone with a 10% or more ownership interest in the provider
- Anyone involved in the day-to-day management of care services
How Do You Fill Out CCRC Form 4?
Follow these steps to complete the form correctly:
- Personal information. Enter your full legal name, home address, and date of birth.
- Education and memberships. List all degrees and certifications. Include every professional association or organization you belong to.
- 20-year employment history. Provide a complete list of employers from the past 20 years. Start with your most recent position and work backward.
- Ownership interests. Report any interests in other CCRC providers or insurance companies. Include the name, location, and your percentage of ownership.
- Legal disclosures. Report any lawsuits, judgments, or criminal charges from the past 20 years.
- Signature. Sign with an original handwritten signature. The Texas Department of Insurance does not accept electronic signatures on this application.
Related Texas Insurance and Care Forms
If you manage or operate a care community in Texas, these related forms and programs may also be relevant to your work:
- Texas Certificate of Insurance – required documentation for Texas insurance coverage
- Texas Aging and Disability Services Forms – state forms for care and support programs
- Financial Affidavit Form – used to document ownership and assets
- Bio Data Template – a general biographical data form for other applications