Life Plan Communities

Application Fees for a Life Plan Communities License

• $75.00 application and renewal fee
• $5.00 processing fee paid at application and renewal
  • (application and processing fees are not refundable)

A. Organization Documents -

1. If a corporation, a copy of the Articles of Incorporation; if a
   partnership, a copy of the partnership agreement; if a limited partnership, a copy of the
   limited partnership agreement; if a trust, a copy of the trust agreement or instrument; if an
   unincorporated association, a copy of the articles of association or other
   membership agreement; if other, explain
2. If applicant is a corporation, attach a copy of the corporate By-laws with attestation by the Secretary and CEO as a true and correct copy
3. Certificate of Good Standing from the Georgia Secretary of State
4. Organizational Chart that reflects the relationship of the applicant to any parent, subsidiary, or affiliated person or organization

B. Biographical List and Affidavits

1. Attach a list of all individuals who are the officers, directors, partners, members,
   administrator, or a stockholder owning more than 10 percent of the stock of the applicant, or
   for any person occupying a similar position or performing similar duties or functions, as
   applicable. Include the full name, business address and position held for each individual so
   listed. Also include a list containing the same information for any parent or affiliated person
   or organization, controlling, controlled by or under common control with, the applicable.
2. Attach a Biographical Affidavit Form GID-59 completed by each natural person listed above.

C. Bond

• The amount of the bond must be sufficient and cannot be less than $100,000 and shall consider the obligations, financial obligations, financial conditions, amount of debts, service provisions, and all other pertinent and application features in determining the bond amount. The bond must be to the benefit of the Commissioner and contain a bond number. 

D. Reservation Agreements and Residency Agreements

• Attached copies of proposed reservation agreements, agendas or agreements to be used in the Life Plan Communities. All must comply with O.C.G.A. 33-45-7.

E. List of Current and Previous Operations

• Attach a list of all facilities currently or previously owned, managed or developed by
  the applicant, or affiliate of the applicant or any principal thereof. 
  • Provide the name, address, city and state of each facility listed and explain the existing or past relationship of the applicant, or affiliate of the applicant, or affiliate of the applicant, or any principal thereof, to
    the facility. 
  • Specify the current status of each facility listed, and include any administrative
    actions or financial problems which existed while the applicant or affiliate of the applicant, or
    any principal thereof, was associated with the facility, and include any such occurrences up to
    one year after the relationship was terminated. 
  • The department may request such other reasonable data, including financial statements, to assist the department in determining the financial viability of the project and the management capabilities of its managers or owners

F. Audited Financial Statements

• Attach the latest financial statement, audited by an independent Certified Public Accountant,
  for the applicant and any parent company. Also, include the latest unaudited financial
  statements for each quarter ended subsequent to the date of the last audit attested to by the
  Chief Financial Officer. 
  • The department may request such other reasonable data and financial information to assist the department in determining the financial viability of the applicant and the management capabilities of its managers and owners.

• Log into www.sircon.com/georgia
• Click on Apply for a License
• Click on New Insurance License and click on Resident and Firm radio buttons, then Continue,
• Enter Firm Name (exactly as your official name) EIN and select Authorized Submitter radio button,
• Scroll down and select Georgia radio button;
• Enter Payment Method and Click Continue to advance to application screens
• Upload all documents
• Complete Attestation

• After submission, an email will be sent confirming submittal.
• The application will be reviewed within ten (10) business days of submittal
• Any deficiencies will be sent via an email to the applicant email address
• All deficiencies must be resolved within 60 days of the email notice
  • If not completed, the application will be closed incomplete
  • Another application submittal including payment of all fees will be required. No refunds for closed incomplete applications.
• If the application is approved, the license will be sent via email as an attachment. Please save the license. Any future copies will require a fee for printing.

Renewals are available early March each year and are due to be filed by June 1st. A late fee of $15 will be imposed if not completed by June 15th. If the license is not renewed it will be inactivated for reason of failure to renew and the company will be required to reapply and could be fined.

Following are the required items to filed in www.Sircon.com/georgia

• Renewal fee of $75.00 plus $5.00 processing fee
• Proof of Continuation of Bond in the amount of $100,000 in favor of the Commissioner executed by a corporate surety insurer authorized to transact business in Georgia
• Audited Financial Statement 
• Annual Statement - GID-060-NT
• Disclosure Statement
• Biographical Affidavit - GID-59-NT for any new individual
• Citizenship Affidavit and ID is only required for a renewal if the previously filed individual is a non-citizen or if the officer, owner, partner or director is new to the organization

Annual Statement GID-060  

Background Statement GID-059

 

O.C.G.A. 33-45

Georgia Rules and Regulations (12-2-51)