Section Ins 1803.01 - Application Procedures(a) All CCRCs seeking a certificate of authority shall file an application with the insurance department.(b) In addition to the information specified in (c) below, the following additional information or supporting material shall accompany each application: (1) The disclosure statement as described under RSA 420-D:4 and Ins 1808;(2) A statement indicating any other state or federal licensure or certification which the continuing care facility may have or be required to have and the current status of such licensure or certification;(3) The appropriate application fee pursuant to Ins 1809;(4) Notarized documents, which shall include the name, address, telephone number and principal business activities of the escrow agent, indicating that an escrow account for entrance fees has been established, when RSA 420-D:10 requires an escrow account for these fees.(c) As part of the application process all CCRCs shall provide a biographical affidavit notarized by a notary public, from any officer, trustee, investor, owner with more than 5 percent ownership, or executive director, or equivalent title, who is not an officer or trustee, that shall include the following: (1) The name and address of the continuing care provider;(2) The name of the affiant;(3) A listing of other names used by the affiant at any time and the reason for, any name changes, if any, for the affiant;(4) The affiant's business address and telephone number;(5) The educational background of the affiant, including the name and location of colleges or universities attended, the dates of attendance, and any degrees earned;(6) A listing of the affiant's membership in professional societies and associations;(7) The affiant's present or proposed position with the provider;(8) A listing of the complete employment record of the affiant up to and including present jobs, positions, directorates, or officerships for the past 10 years giving the dates of employment, the name and address of each employer and the job title held;(9) A statement as to whether or not the present employer may be contacted;(10) A statement as to whether or not former employers may be contacted;(11) A statement as to whether or not the affiant has ever been in a position which required a fidelity bond;(12) If the answer to (11) above is affirmative, and if any claims were made on the bond, the affiant shall state the details of each such claim;(13) A statement as to whether or not the affiant has ever been denied an individual or position schedule fidelity bond or if any such bond has ever been cancelled or revoked;(14) If the answer to (13) above is affirmative, a statement as to the details of each denial, cancellation or revocation;(15) A listing of the professional, occupational, and vocational licenses issued by any public or governmental licensing agency or regulatory authority which the affiant presently holds or has held in the past, including the date the license was issued, the issuer of the license, the date the license was terminated and the reason for termination;(16) A statement as to whether or not the affiant has, within the last 10 years, been refused a professional, occupational, or vocational license by any public or governmental licensing agency or regulatory authority, or had any such license held suspended or revoked;(17) If the answer to (16) above is affirmative, the affiant shall state the details of each denial, cancellation, or revocation;(18) A listing of the continuing care providers or health care facilities in which the affiant controls, directly or indirectly, or owns legally or beneficially 10 percent or more of the outstanding voting stock, in voting power;(19) A statement by the affiant as to whether the affiant or members of his or her immediate family will subscribe to or own, beneficially or of record, any shares of stock in the continuing care provider or in any affiliate of the continuing care provider;(20) If any of the shares or stock noted in the answer to (19) above are pledged or hypothecated in any way, the affiant shall provide an explanation of these circumstances;(21) A statement by the affiant as to whether or not he or she has ever been adjudged bankrupt;(22) A statement by the affiant, and details of if affirmative, as to whether the affiant has ever been convicted or had a sentence imposed or suspended or had pronouncement of a sentence suspended or been pardoned for conviction of or pleaded guilty or nolo contendre to an information or indictment charging any felony, or charging a misdemeanor involving embezzlement, theft, larceny, or mail fraud, or charging a violation of any corporate securities statute or any insurance law;(23) Whether the affiant has ever been the subject of any disciplinary proceedings of any federal or state regulatory agency, and details if affirmative;(24) A statement by the affiant as to whether or not any company has ever been charged as in (22) above, allegedly as a result of any action or conduct on the part of the affiant;(25) A statement by the affiant as to whether or not the affiant has ever been an officer, director, trustee, investment committee member, key employee, or controlling stockholder of any company or organization which, while the affiant occupied any such position or capacity with respect to it, became insolvent or was placed under supervision or in receivership, rehabilitation, liquidation or conservatorship;(26) A statement by the affiant, and details if affirmative, as to whether or not the certificate of authority or license to do business of any provider or company of which the affiant was an officer, or director or key management person has ever been suspended or revoked while the affiant occupied such position; and(27) A dated signature of the affiant by which the affiant certifies that he or she is acting on his or her own behalf and that the foregoing statements are true and correct to the best of the affiant's knowledge and belief.(d) The applicant shall provide the following information in the application: (1) The name of the continuing care facility;(2) The type of business organization of the continuing care facility;(3) Under which state's laws the facility is organized;(4) The facility's home address, if within the United States or the United States branch office if the home address is outside of the United States;(5) The principal mailing address;(6) Whether the department ever issued a temporary certificate of authority to the applicant and, if yes, the date of expiration;(7) Certification that the applicant, if issued a certificate of authority, will abide by the applicable rules of the department;(8) Certification that the applicable requirements of RSA 420-D have been met;(9) Whether the license or authority of the CCRC facility, or affiliated facility of a controlling organization, has ever been revoked, suspended or canceled in any jurisdiction;(10) Whether any previous application of the CCRC facility, or affiliated facility of a controlling organization, for a license or authority has been denied in any jurisdiction;(11) If an affirmative answer is given to the information requested in (9) or (10) above, the details of any revocation, suspension, cancellation or denial; and(12) Authorized signature indicating that, to the best of the signer's knowledge and belief, the information in the application is true and complete, and the signer's printed name and title, and the date signed.(e) The commissioner shall act upon applications received within a reasonable time, as set forth in RSA 541-A:29,II(a).(f) CCRCs who have applications pending shall keep their application and any accompanying information or supporting material current, and file any amendments or other changes on a timely basis.(g) Any applicant whose application is rejected shall be entitled to a hearing in accordance with the provisions of RSA 541, RSA 541-A and Ins 200 and shall be so notified.N.H. Admin. Code § Ins 1803.01
#7014, eff 7-1-99, EXPIRED: 7-1-07
New. #8991, eff 10-1-07
Amended by Volume XXXV Number 45, Filed November 12, 2015, Proposed by #10944, Effective 10/8/2015, Expires 10/8/2025.