Get Ct Dlg Flis Licapp

Filling out the Ct Dlg Flis Licapp online is an essential step for licensing various health-related facilities in Connecticut. This guide provides a clear and supportive approach to help users navigate through the requirements and complete the application efficiently.

Follow the steps to complete the application successfully.

1. Click ‘Get Form’ button to obtain the form and access it in the online editor.
2. Indicate the type of application by checking the appropriate box for either 'Initial' or 'Renewal.' This section helps to clarify the nature of your application.
3. Select the specific licensed level of care that applies to your facility by checking the relevant box or boxes from the provided list.
4. Provide the facility 'doing business as' (d/b/a) name, business address, and contact information. Ensure that the details are accurate and complete to avoid delays.
5. If applicable, indicate the bed capacity requested for each level of care. Make sure to specify the number of beds and any hemodialysis stations or bassinets accurately.
6. Disclose the federal employer identification number (EIN) associated with your facility to ensure proper identification during the licensing process.
7. Provide details about the legal entity that owns or operates the facility, including the licensee's name and address, as well as the mailing address if different.
8. Select the applicable legal structure of the entity by checking the relevant box, such as 'Individual/Sole Proprietor' or 'Limited Liability Company.'
9. Confirm whether the entity is authorized to transact business in the state of Connecticut by selecting 'Yes' or 'No.'
10. List the agent for service of the licensee, including their name, address, and phone number to ensure effective communication.
11. Attach the required organizational chart as well as any additional documentation related to ownership and corporate structure as specified.
12. Submit the certificate of malpractice and public liability insurance, ensuring to provide only acceptable forms as listed.
13. Attach evidence of worker’s compensation insurance coverage, ensuring compliance with the requirements outlined.
14. Provide information on the ownership of the real property associated with your facility, including names and contact details.
15. Complete and attach the Annual Fire Marshal’s Certificate of Inspection Form, which must be signed appropriately.
16. Lastly, ensure to fill out the affidavit of owner section. Sign and date the application before submission.
17. Once all sections are completed, you can save changes, download, print, or share the form as required.

Begin filling out the Ct Dlg Flis Licapp online today to ensure your facility is properly licensed.