2022-11-15T10:11:30-06:00 2021-12-31 366055558 GRANT THORNTON LLP 75 STATE ST 13TH FLOOR BOSTON MA 02109 990 2021-01-01 362612058 DELTA DENTAL OF ILLINOIS DELT 6307184700 111 SHUMAN BOULEVARD NAPERVILLE IL 60563 TERRI BON VP FINANCE & CFO 6307184700 2022-11-15 1 TERRI BON 999009999 ERIN COUTURE P01390592 3128560200 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z TERRI BON 111 SHUMAN BOULEVARD NAPERVILLE IL 60563 911698708 0 X WWW.DELTADENTALIL.COM X 1967 IL IMPROVE THE ORAL HEALTH OF ILLINOIS RESIDENTS BY PROVIDING DENTAL BENEFITS & OTHER SERVICES. 12 7 210 0 0 0 0 0 770720048 891970991 1087215 -905738 670693 25560 772477956 891090813 9634797 3191505 665240359 813078791 21832679 21655562 0 0 0 56024720 46592271 752732555 884518129 19745401 6572684 219389803 236756385 68182495 78338425 151207308 158417960 IMPROVE THE ORAL HEALTH OF ILLINOIS RESIDENTS BY PROVIDING DENTAL BENEFITS & OTHER SERVICES. 0 0 861414617 3191505 891970991 DELTA DENTAL OF ILLINOIS (DDIL) IS A NOT-FOR-PROFIT CORPORATION WHICH MAINTAINS AND OPERATES A DENTAL CARE PLAN TO APPROXIMATELY 2,602,000 INDIVIDUALS. DDIL IS COMMITTED TO ITS MISSION TO DELIVER EXCEPTIONAL SERVICES TO OUR STAKEHOLDERS AND IMPROVE THE ORAL HEALTH OF THE COMMUNITIES WE SERVE. IN 2021, DDIL GRANTED $3,191,505 TO DELTA DENTAL OF ILLINOIS FOUNDATION, A 501(C)(3) CHARITABLE ORGANIZATION TO PROMOTE THE IMPROVEMENT OF DENTAL EDUCATION AND ACCESS TO DENTAL CARE IN ILLINOIS. 861414617 0 0 0 1 0 0 0 0 0 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 0 1 68427 0 1 210 1 0 0 0 0 0 0 1 0 X 12 7 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X TERRI BON 6307184700 111 SHUMAN BOULEVARD NAPERVILLE IL 60563 BRIAN SAMMARCO CHAIRMAN 5.00 0.00 X X 82779 0 0 DR GENARO ROMO VICE CHAIR 3.00 0.00 X 55998 0 0 JOSEPH LEO COMMITTEE CHAIR 3.00 0.00 X 48132 0 0 DR RON RIGGINS COMMITTEE CHAIR 3.00 0.00 X 47800 0 0 DR FRANK MAGGIO PAST CHAIR 2.00 0.00 X 45800 0 0 LORI GOLD PATTERSON COMMITTEE CHAIR 3.00 0.00 X 44896 0 0 OMAR DUQUE DIRECTOR 2.00 0.00 X 43111 0 0 DEAN MALONE COMMITTEE CHAIR 3.00 0.00 X 43097 0 0 JANE HAYS DIRECTOR 2.00 0.00 X 42587 0 0 DR DAVID MILLER DIRECTOR 2.00 0.00 X 42300 0 0 DARRYL RODGERS DIRECTOR 2.00 0.00 X 21050 0 19500 DR CISSY FURUSHO DIRECTOR 2.00 0.00 X 39344 0 0 JOHN MAPLES PRESIDENT & CEO 40.00 5.00 X 1751011 0 6175 TERRI BON TREAS, SEC., VP OF FIN & CFO 40.00 5.00 X 663959 0 37078 KARYN GLOGOWSKI VP/DIRECTOR OF SALES 40.00 0.00 X 472491 0 37622 ALEXANDRA KOTELON CORPORATE COUNSEL 40.00 5.00 X 390922 0 24974 MICHAEL WHITE VP & GM TRUASSURE 40.00 0.00 X 371334 0 1846 DR SHELIA STROCK VP DENTAL SERVICES 40.00 0.00 X 341703 0 30427 ANN MARIE WALKER VP CORP. COMMUNICATIONS 40.00 0.00 X 324833 0 28500 TERRY MADDOX VP SERVICE OPERATIONS 40.00 0.00 X 282100 0 32951 LORA VITEK EXECUTIVE DIRECTOR OF FOUNDATION 5.00 40.00 X 224750 0 17793 DANIEL BATTISTA SR. SALES EXECUTIVE 40.00 0.00 X 310656 0 21461 ROBERT MAXWELL SR SALES EXECUTIVE 40.00 0.00 X 248397 0 38191 STACY BEITZEL MANAGER CLIENT RELATIONS 40.00 0.00 X 235889 0 22956 JOHN DECRISTOFARO CONTROLLER & DIR ERM 40.00 0.00 X 217763 0 21701 LINDA NASTI SR. SALES EXECUTIVE 40.00 0.00 X 227755 0 6448 BERNARD GLOSSY FORMER CEO & PRESIDENT 0.00 0.00 X 105783 0 0 MICHAEL BUSSE FORMER COMMITTEE CHAIR 0.00 0.00 X 68111 0 0 6794351 0 347623 33 1 1 0 WYSSTA SERVICES 2801 HOOVER ROAD STEVENS POINT WI 54481 ADMIN SYSTEMS 2576873 RYAN COMPANIES US INC 700 OAKMONT LANE SUITE 100 WESTMONT IL 60559 BUILDING MANAGER\CONTRACTOR 2535289 CHANGE HEALTHCARE PAYMENT MANAGEMENT 3055 LEBANON PIKE STE 100 NASHVILLE TN 37214 INVOICE PRINTING 2409823 THE MEYOCKS GROUP 6800 LAKE DRIVE STE 150 WEST DES MOINES IA 50266 ADVT & MARKETING 1156177 ENCARA INC 4818 STARKEY ROAD ROANOKE VA 24018 MARKETING 1019615 34 PREMIUMS 524114 891970991 891970991 891970991 -5038034 -5038034 25560 0 25560 25560 25560 24740191 20607895 4132296 4132296 4132296 891090813 891970991 0 -880178 3191505 3191505 813078791 813078791 5760739 5760739 105783 105783 11024515 6424542 4599973 1282061 548722 733339 2281341 1239790 1041551 1201123 504418 696705 359971 359971 277030 277030 282274 282274 1616004 378480 1237524 2485609 109380 2376229 881672 856068 25604 16500742 16725566 -224824 3299473 2001904 1297569 27116 5097 22019 115511 9393 106118 988286 342626 645660 533208 533208 BROKER COMMISSIONS 13210915 13210915 PRINTING & PUBLICATIONS 1780054 1577824 202230 BUILDING REDESIGN 1635446 1635446 INSURANCE DEPT. FEES 1200515 1149786 50729 1398445 59810 1338635 884518129 861414617 23103512 0 40391934 33387443 44024149 59324266 866506 1158608 24859299 12363713 13458726 12495586 85836998 92313993 34483315 37698193 0 328175 378296 219389803 236756385 19180062 19162450 7064409 7764962 41938024 51411013 68182495 78338425 X 0 0 0 0 151207308 158417960 151207308 158417960 219389803 236756385 6572684 637968 0 X X 0 1 X 1 0 0 0 0 0 1 0 3625539 3625539 16066877 7469639 8597238 2634288 2377100 257188 2532595 2516974 15621 12495586 CLOSELY-HELD EQUITY INTERESTS 19219379 F INVESTMENT IN JOINT VENTURES 11593277 F LIMITED PARTNERSHIP 6885537 F 37698193 SELF-INSURED UNPAID CLAIMS 33453109 UNPAID CLAIMS AND CLAIMS ADJUSTMENT 14858000 INTERCOMPANY PAYABLE 3099904 51411013 X 237958894 0 237958894 653131919 653131919 891090813 229967438 0 229967438 282274 654268417 654550691 884518129 PART X, LINE 2: ASC 740 FOOTNOTE DELTA DENTAL OF ILLINOIS IS ORGANIZED AS A NONPROFIT DENTAL CARE PLAN FOR FEDERAL INCOME TAX PURPOSES UNDER SECTION 501(C)(4) OF THE INTERNAL REVENUE CODE AND, AS SUCH, DOES NOT PAY FEDERAL INCOME TAXES. DELTA DENTAL OF ILLINOIS IS EXEMPT FROM STATE INCOME TAXES. THERE WERE NO SIGNIFICANT PENALTIES OR INTEREST RECOGNIZED DURING THE YEAR OR ACCRUED AT YEAR END. PART XI, LINE 4B - OTHER ADJUSTMENTS: ASC REVENUE 653,588,725. GROSS RENTAL INCOME 25,560. NII\EQUITY IN SUBS -5,038,034. REALIZED GAINS 4,132,296. MISC. REVENUE 423,372. PART XII, LINE 4B - OTHER ADJUSTMENTS: ASC CLAIMS 625,535,189. ASC ADMIN FEE 28,053,536. DEPRECIATION 642,321. DISCOUNT TIRES CLAIMS 37,371. 1 DELTA DENTAL OF ILLINOIS FOUNDATION 111 SHUMAN BOULEVARD NAPERVILLE IL 60563 262700504 501(C)(3) 3191505 0 PROMOTE ORAL HEALTH OF IL RESIDENTS 1 PART I, LINE 2: GRANTS AND OTHER ASSISTANCE DELTA DENTAL OF ILLINOIS DIRECTORS AND OFFICERS HAVE THE MAJORITY OF SEATS ON THE DELTA DENTAL OF ILLINOIS FOUNDATION BOARD, AND THEREFORE MONITOR AND APPROVE HOW GRANT MONEY IS USED AND TRACKED. X 1 1 X X X X X 0 0 0 0 0 0 0 1 0 JOHN MAPLES PRESIDENT & CEO 783107 0 937040 0 30864 0 0 0 6175 0 1757186 0 0 0 TERRI BON TREAS, SEC., VP OF FIN & CFO 431809 0 222592 0 9558 0 26000 0 11078 0 701037 0 0 0 KARYN GLOGOWSKI VP/DIRECTOR OF SALES 272146 0 193967 0 6378 0 26000 0 11622 0 510113 0 0 0 ALEXANDRA KOTELON CORPORATE COUNSEL 249277 0 132836 0 8809 0 19500 0 5474 0 415896 0 0 0 MICHAEL WHITE VP & GM TRUASSURE 237142 0 122346 0 11846 0 0 0 1846 0 373180 0 0 0 DR SHELIA STROCK VP DENTAL SERVICES 220357 0 111836 0 9510 0 26000 0 4427 0 372130 0 0 0 ANN MARIE WALKER VP CORP. COMMUNICATIONS 212788 0 102486 0 9559 0 26000 0 2500 0 353333 0 0 0 DANIEL BATTISTA SR. SALES EXECUTIVE 62598 0 244089 0 3969 0 19500 0 1961 0 332117 0 0 0 TERRY MADDOX VP SERVICE OPERATIONS 184925 0 87617 0 9558 0 26000 0 6951 0 315051 0 0 0 ROBERT MAXWELL SR SALES EXECUTIVE 95958 0 145051 0 7388 0 26000 0 12191 0 286588 0 0 0 STACY BEITZEL MANAGER CLIENT RELATIONS 139095 0 89708 0 7086 0 22774 0 182 0 258845 0 0 0 LORA VITEK EXECUTIVE DIRECTOR OF FOUNDATION 140744 0 74449 0 9557 0 11095 0 6698 0 242543 0 0 0 JOHN DECRISTOFARO CONTROLLER & DIR ERM 171010 0 44449 0 2304 0 13329 0 8372 0 239464 0 0 0 LINDA NASTI SR. SALES EXECUTIVE 69994 0 153005 0 4756 0 0 0 6448 0 234203 0 0 0 BERNARD GLOSSY FORMER CEO & PRESIDENT 0 0 0 0 105783 0 0 0 0 0 105783 0 0 0 MICHAEL BUSSE FORMER COMMITTEE CHAIR 0 0 0 0 68111 0 0 0 0 0 68111 0 0 0 PART I, LINE 1A HEALTH AND SOCIAL DUES THE OFFICERS OF THE ORGANIZATION ARE REIMBURSED FOR HEALTH CLUB MEMBERSHIP DUES UP TO $100 PER MONTH PER COMPANY POLICY AND IT IS INCLUDED ON RESPECTIVE W-2S. NO OFFICERS PARTOOK IN THIS BENEFIT THIS YEAR. THE CEO'S SOCIAL DUES (COUNTRY CLUB) ARE PAID BY THE ORGANIZATION. PART I, LINE 7 NON-FIXED PAYMENTS AS INDICATED IN SCHEDULE J, PART II, PERSONS LISTED ON FORM 990, PART VII, SECTION A RECEIVED A BONUS BASED ON PERFORMANCE AND THE FINANCIAL RESULTS OF THE ORGANIZATION. THIS BONUS WAS APPROVED BY THE BOARD. DR CISSY FURUSHO DIRECTOR 258305 COMPENSATION 0 DR RONALD RIGGINS DIRECTOR 156994 COMPENSATION 0 DR GENARO ROMO DIRECTOR 542665 COMPENSATION 0 SCHEDULE L, PART IV: TRANSACTIONS WITH INTERESTED PERSONS(A) NAME OF PERSON: DR. CISSY FURUSHO THROUGH DRS KOLLMAN & FURUSHO DENTISTRY(D) DESCRIPTION OF TRANSACTION: PAYMENTS TO DENTAL PRACTICE FOR DENTAL SERVICES PROVIDED UNDER DENTAL INSURANCE POLICY. COMPENSATION WAS AT AN ARM'S LENGTH.(A) NAME OF PERSON: DR. RONALD RIGGINS THROUGH RIVERSIDE DENTISTRY LLC(D) DESCRIPTION OF TRANSACTION: PAYMENTS TO DENTAL PRACTICE FOR DENTAL SERVICES PROVIDED UNDER DENTAL INSURANCE POLICY. COMPENSATION WAS AT AN ARM'S LENGTH.(A) NAME OF PERSON: DR. GENARO ROMO THROUGH ROMO DENTAL PC & ROMO DENTAL II PC(D) DESCRIPTION OF TRANSACTION: PAYMENTS TO DENTAL PRACTICE FOR DENTAL SERVICES PROVIDED UNDER DENTAL INSURANCE POLICY. COMPENSATION WAS AT AN ARM'S LENGTH. FORM 990, PART VI, SECTION A, LINE 6 MEMBERS OR STOCKHOLDERS UNDER THE ENABLING STATUTE THAT GOVERNS THE ORGANIZATION - THE ILLINOIS DENTAL SERVICE PLAN ACT - THE MEMBERS OF DELTA DENTAL OF ILLINOIS ARE THE PARTICIPATING DENTISTS (DEFINED AS ANY DENTIST LICENSED IN ILLINOIS TO PRACTICE DENTISTRY WHO IS REPUTABLE AND IN GOOD STANDING AND HAS SIGNED AN AGREEMENT TO BECOME A PARTICIPATING DENTIST OF THE ORGANIZATION) AND THE GROUP SUBSCRIBERS WHO PURCHASE A DENTAL BENEFIT PROGRAM FROM THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A MEMBERS OR STOCKHOLDERS WHO MAY ELECT AT THE ANNUAL MEMBERSHIP MEETING OF THE ORGANIZATION, THE MEMBERS REFERENCED IN PART VI, LINE 6 ELECT THE MEMBERS OF THE GOVERNING BODY, I.E. DIRECTORS, WHOSE TERM OF DIRECTORSHIP HAS EXPIRED. FORM 990, PART VI, SECTION A, LINE 7B MEMBERS OR STOCKHOLDERS WHO MAY ELECT AT THE ANNUAL MEMBERSHIP MEETING OF THE ORGANIZATION, THE MEMBERS REFERENCED IN PART VI, LINE 6 ELECT THE MEMBERS OF THE GOVERNING BODY, I.E. DIRECTORS, WHOSE TERM OF DIRECTORSHIP HAS EXPIRED. FORM 990, PART VI, SECTION B, LINE 11B THE BOARD OF THE ORGANIZATION RETAINS THE SERVICES OF AN INDEPENDENT CPA FIRM TO ASSIST IN THE PREPARATION OF THE ORGANIZATION'S FORM 990. THE CPA FIRM ASSISTS MANAGEMENT IN PREPARING AND FINALIZING THE FORM 990. THE DRAFT OF FORM 990, INCLUDING ALL SCHEDULES, IS REVIEWED BY THE AUDIT AND FINANCE COMMITTEE, AND THEN DISTRIBUTED TO ALL VOTING MEMBERS OF THE GOVERNING BODY, I.E. THE DIRECTORS. THE ORGANIZATION'S MANAGEMENT, AND IF NEEDED ITS CPA FIRM, ADDRESS ANY QUESTIONS OR COMMENTS SUBMITTED BY THE ORGANIZATION'S GOVERNING BODY BEFORE FILING ITS FORM 990. AFTER THE AUDIT AND FINANCE COMMITTEE'S REVIEW AND MANAGEMENT ADDRESSES QUESTIONS OR COMMENTS FROM THE DIRECTORS, THE DRAFT FORM 990 IS FINALIZED AND FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C CONFLICT OF INTEREST POLICY MONITORING & ENFORCEMENT LEGAL COUNSEL FOR THE ORGANIZATION REVIEWS THE ORGANIZATION'S CONFLICT OF INTEREST POLICY ANNUALLY WITH THE OFFICERS, DIRECTORS (TRUSTEES) AND KEY EMPLOYEES. AFTER THIS REVIEW, THE INDIVIDUALS OCCUPYING THESE POSITIONS ARE REQUIRED TO COMPLETE A CONFLICT OF INTEREST DISCLOSURE STATEMENT. POTENTIAL CONFLICTS ARE LOGGED WITH THE SECRETARY OF THE ORGANIZATION AND ANY CHANGES TO THE DISCLOSURE FORM ARE TO BE REPORTED TO THE CORPORATE COUNSEL OF THE ORGANIZATION. IF A CONFLICT ARISES, THESE INDIVIDUALS ARE ASKED TO RECUSE THEMSELVES. FORM 990, PART VI, SECTION B, LINE 15 PROCESS OF DETERMINING COMPENSATION CEO AND OTHER TOP MANAGEMENT OFFICIALS COMPENSATION IS REVIEWED BY THE BOARD OF DIRECTORS. THE BOARD PERIODICALLY ENGAGES AN INDEPENDENT CONSULTING FIRM TO ADVISE OF COMPENSATION LEVELS OF SIMILARLY SITUATED CEOS AND OTHER TOP MANAGEMENT OFFICIALS BASED UPON SURVEYS AND DATA PROVIDED BY OTHER ORGANIZATIONS AS LISTED ON THEIR FORM 990. THIS DATA, OR THE DATA REPRESENTED TO THE COMPENSATION COMMITTEE AT SCHEDULED MEETINGS AND MINUTES OF THESE MEETINGS ARE CONTEMPORANEOUSLY PREPARED. THE COMMITTEE MAKES A RECOMMENDATION FOR CEO COMPENSATION TO THE BOARD FOR APPROVAL. EXECUTIVE COMPENSATION IS REVIEWED ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19 HOW DOCUMENTS ARE MADE AVAILABLE TO THE PUBLIC GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE AVAILABLE THROUGH APPLICABLE GOVERNMENTAL AGENCIES; THE CONFLICT OF INTEREST POLICY IS AVAILABLE UPON WRITTEN REQUEST TO THE ORGANIZATION. PART XII, LINE 2B BEGINNING WITH CALENDAR YEAR 2021 THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS WERE PREPARED ON THE STATUTORY BASIS OF ACCOUNTING. HOWEVER, IN ORDER TO PROVIDE FULL TRANSPARENCY AND ACCURATELY REPRESENT THE ACTIVITIES OF THE ORGANIZATION, THE FORM 990 IS PREPARED USING THE ACCRUAL METHOD OF ACCOUNTING. THE RECONCILIATION BETWEEN THE AUDITED STATUTORY FINANCIAL STATEMENTS AND THE FINANCIALS PRESENTED ON THE FORM 990 IS ILLUSTRATED IN THE SCHEDULE D RECONCILIATIONS. DELTA DENTAL OF ILLINOIS FOUNDATION 111 SHUMAN BLVD NAPERVILLE IL 60563 262700504 ORAL HEALTH IL 501(C)(3) LINE 7 DDIL 1 NORTHWINDS TECHNOLOGY SOLUTION 111 SHUMAN BOULEVARD NAPERVILLE IL 60563 TECHNOLOGY DE DDIL & DDWI -6279707 16989438 0 1 0.50000 TRUASSURE INSURANCE COMPANY 111 SHUMAN BLVD NAPERVILLE IL 60563 363757528 DENTAL INS. IL DDIL C -811324 13818037 1.00000 1 PROTEC INSURANCE COMPANY 111 SHUMAN BLVD NAPERVILLE IL 60563 320416457 HEALTH INS. IL DDIL C 750071 7778972 1.00000 1 TRUASSURE INSURANCE COMPANY OF COLORADO 111 SHUMAN BLVD NAPERVILLE IL 60563 812595283 DENTAL INS CO DDIL C 9480 2122155 1.00000 1 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 DELTA DENTAL OF ILLINOIS FOUNDATION B 2847439 FMV NORTHWINDS TECHNOLOGY SOLUTIONS LLC B 9250000 FMV NORTHWINDS TECHNOLOGY SOLUTIONS LLC M 9288609 FMV DELTA DENTAL OF ILLINOIS FOUNDATION O 344066 FMV TRUASSURE INSURANCE COMPANY P 1563118 FMV PROTEC INSURANCE COMPANY P 187942 FMV NORTHWINDS TECHNOLOGY SOLUTIONS LLC P 305965 FMV NORTHWINDS TECHNOLOGY SOLUTIONS LLC Q 2961516 FMV PROTEC INSURANCE COMPANY R 5038042 FMV