2018-05-23T08:56:29-05:00 2017-12-31 450250958 EIDE BAILLY LLP 200 EAST 10TH ST PO BOX 5125 SIOUX FALLS SD 571175125 990 2017-01-01 460309258 DELTA DENTAL OF SOUTH DAKOTA DELT 6052247345 PO BOX 1157 PIERRE SD 57501 SCOTT JONES PRESIDENT & CEO 6052247345 2018-05-08 1 LAURIE HANSON P00851848 6053391999 2018-05-08 2017 2022-09-23 18:48:47Z SCOTT JONES PO BOX 1157 PIERRE SD 57501 169242778 0 X WWW.DELTADENTALSD.COM X 1963 SD DEDICATED TO ADVANCING AND PROMOTING THE IMPROVEMENT OF ORAL HEALTH. 14 6 92 0 2763450 -12290 0 0 148927898 155980738 734400 1640293 2569891 2753015 152232189 160374046 3130561 3132542 0 0 6231267 6776250 0 0 0 140039074 147337124 149400902 157245916 2831287 3128130 49074576 54224300 12612359 12598765 36462217 41625535 DELTA DENTAL OF SOUTH DAKOTA IS DEDICATED TO ADVANCING AND PROMOTING THE IMPROVEMENT OF ORAL HEALTH. 0 0 143740034 3132542 155980738 DELTA DENTAL PAID THROUGH ITS CONTRACTS WITH INDEPENDENT DENTISTS 621,835 CLAIMS FOR DENTAL BENEFIT SERVICES FOR APPROXIMATELY 289,629 INDIVIDUALS WITH GROUP PLANS 3,707 INDIVIDUALS WITH DENTAL ACCIDENT PLANS, 114,275 SOUTH DAKOTA MEDICAID RECIPIENTS AND 95,000 NATIVE AMERICANS UNDER ABERDEEN AREA HEALTH SERVICES. DELTA DENTAL ALSO GRANTED THE DELTA DENTAL OF SOUTH DAKOTA FOUNDATION, A 501(C)(3) CHARITABLE ORGANIZATION, $2,873,661 TO PROMOTE THE IMPROVEMENT OF ORAL HEALTH. 143740034 0 0 0 0 0 0 0 0 0 1 0 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 3865 0 1 92 1 1 1 0 0 0 0 0 X 14 6 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X KIRBY SCOTT 6052247345 720 N EUCLID AVE PIERRE SD 57501 DALE GIBSON DDS CHAIR 2.00 1.00 X X 14000 0 0 PAUL REZICH DDS VICE CHAIR 1.00 1.00 X X 9000 0 0 GREG GERTSEN DDS SECRETARY 1.00 0.00 X X 8100 0 0 JOHN CLAUSEN TREASURER 2.00 1.00 X X 13100 0 0 MONTY BECHTOLD DDS DIRECTOR 1.00 1.00 X 8000 0 0 STEVE CULHANE DIRECTOR 1.00 0.00 X 7000 0 0 JEFF FEIOCK DDS DIRECTOR 1.00 0.00 X 6000 0 0 G VERNE GOODSELL DIRECTOR 1.00 0.00 X 9000 0 0 GREG HANSON DDS DIRECTOR 1.00 0.00 X 8000 0 0 PAT HERMANSON DDS UNTIL MAY 2017 DIRECTOR 1.00 0.00 X 4000 0 0 ELLEN LEE DIRECTOR 1.00 1.00 X 8500 0 0 ANLEE ROLA DDS DIRECTOR 1.00 1.00 X 8500 0 0 JIM RUSSELL DIRECTOR 1.00 0.00 X 9100 0 0 THANE CRUMP DDS DIRECTOR 1.00 1.00 X 7000 0 0 TOM HUBER BEG MAY 2017 DIRECTOR 1.00 0.00 X 4000 0 0 JERRY NACTHIGAL UNTIL APRIL 2017 DIRECTOR 1.00 1.00 X 1000 0 0 SCOTT JONES PRESIDENT & CEO 40.00 1.00 X 1170097 0 46791 KIRBY SCOTT VP OF FINANCE/CFO 40.00 1.00 X 195935 0 31228 GENE TETZLAFF VP - INFO TECHNICIAN 40.00 1.00 X 182930 0 47443 MICK HECKENLAIBLE VP OF OPERATIONS 40.00 1.00 X 191130 0 38133 JEFF MILLER VP OF UNDERWRITING 40.00 1.00 X 188028 0 40045 NANCE ORSBON VP - PROF RELATIONS 40.00 1.00 X 217496 0 33403 CONNIE HALVERSON VP - PUBLIC RELATIONS 20.00 20.00 X 148695 0 42919 GARY BJERRUM DDS DENTIST 0.00 40.00 X 165529 0 28199 GEORGE ALLEN DATA ANALYST 40.00 0.00 X 111459 0 18626 SARA GREEN UNDERWRITING ANALYST 40.00 0.00 X 114292 0 23265 2809891 0 350052 10 0 1 0 237 PREMIUM EARNED 812900 155980738 155980738 155980738 916503 916503 38700 49135 -10435 -10435 -10435 9543387 8819597 723790 723790 723790 MANAGEMENT SERVICE FEES 541610 2763450 2763450 2763450 160374046 155980738 2763450 1629858 3132542 3132542 2052420 2052420 2370272 2370272 1170136 1170136 847836 847836 335586 335586 1041 1041 75756 75756 70836 70836 204352 204352 376829 376829 609021 609021 52224 52224 64484 64484 93798 93798 230051 230051 314055 314055 79359 79359 CLAIMS INCURRED 140607492 140607492 MANAGEMENT SERVICE EXPE 2333500 2333500 COMMISIONS 1170968 1170968 PREMIUM TAXES 558118 558118 495240 495240 157245916 143740034 13505882 0 7602 4839 5802614 7375880 9746302 9797366 134148 208472 7376854 3270715 3856635 4106139 28678015 31939709 576194 542368 273066 249527 49074576 54224300 3898548 3806941 8713811 8791824 12612359 12598765 X 36462217 41625535 0 0 0 0 36462217 41625535 49074576 54224300 3128130 2035188 0 X 0 1 X 1 0 397371 397371 4942419 1680167 3262252 2037064 1590548 446516 4106139 UNPAID CLAIMS AND CLAIMS INCURRED BUT NOT REPORTED 4811000 UNPAID CLAIMS ADJUSTMENT EXPENSES 481100 COST PLUS GROUP DEPOSITS 74100 DEFERRED PREMIUMS 1208224 SUPPLEMENTAL RETIREMENT PLAN LIABILITY 2217400 8791824 X 160054033 2035188 -2333500 -298312 160352345 70836 -49135 21701 160374046 154890715 49135 49135 154841580 70836 2333500 2404336 157245916 PART X, LINE 2: THE COMPANY HAS BEEN DETERMINED TO BE EXEMPT FROM FEDERAL INCOME TAX UNDER SECTION 501(C)(4) OF THE INTERNAL REVENUE CODE, EXCEPT FOR UNRELATED BUSINESS INCOME. ACCOUNTING STANDARDS PRESCRIBE A RECOGNITION THRESHOLD OF MORE LIKELY THAN NOT, AND A MEASUREMENT ATTRIBUTE FOR ALL TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN ON A TAX RETURN, IN ORDER FOR THOSE TAX POSITIONS TO BE RECOGNIZED IN THE FINANCIAL STATEMENTS. AT DECEMBER 31, 2017 AND 2016, THE COMPANY BELIEVES THAT THERE ARE NO UNCERTAIN TAX POSITIONS OR LIABILITIES, OR INTEREST AND PENALTIES ASSOCIATED WITH UNCERTAIN TAX POSITIONS. IF THE COMPANY HAD INTEREST AND PENALTIES RELATED TO UNCERTAIN TAX POSITIONS, IT WOULD BE ACCOUNTED FOR AS A COMPONENT OF INCOME TAX EXPENSE. PART XI, LINE 2D - OTHER ADJUSTMENTS: EXPENSES RECORDED IN REVENUE ON FINANCIAL STATEMENTS -2,333,500. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES RECLASSIFIED TO REVENUE FOR 990 -49,135. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES RECLASSIFIED TO REVENUE FOR 990 49,135. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES RECORDED IN REVENUE ON FINANCIAL STATEMENTS 2,333,500. 0 DELTA DENTAL OF SOUTH DAKOTA FOUNDATION 804 NORTH EUCLID SUITE 1 PIERRE SD 57501 911776857 501(C)(3) 2873661 PROMOTE DENTAL HEALTH IN SOUTH DAKOTA CAPITAL AREA UNITED WAY 221 SOUTH CENTRAL AVE PIERRE SD 57501 460403398 501(C)(3) 61116 DISTRIBUTING CHARITABLE DONATIONS AVERA HEALTH 3900 WEST AVERA DRIVE SIOUX FALLS SD 57108 460422673 501(C)(3) 35730 CANCER CENTER IN PIERRE, SD. COMMUNITY YOUTH AND INVOLVED 19 E MAIN AVE FT PIERRE SD 57532 460331926 501(C)(3) 100600 BUILDING IMPROVEMENTS SD COMMUNITY FOUNDATION 1714 LINCOLN AVE PIERRE SD 57501 460398115 501(C)(3) 6000 COMMUNITY SUPPORT SDSU FOUNDATION 815 MEDARY AVE BROOKINGS SD 57006 460273801 501(C)(3) 25000 SCHOLARSHIP IN MEMORY OF BOARD MEMBER 6 0 X 1 1 X X X X X X 0 1 0 0 0 0 0 0 0 SCOTT JONES PRESIDENT & CEO 456828 0 706459 0 6810 0 26150 0 20641 0 1216888 0 0 0 KIRBY SCOTT VP OF FINANCE/CFO 145308 0 49875 0 752 0 19837 0 11391 0 227163 0 0 0 GENE TETZLAFF VP - INFO TECHNICIAN 134450 0 47670 0 810 0 18987 0 28456 0 230373 0 0 0 MICK HECKENLAIBLE VP OF OPERATIONS 141600 0 48720 0 810 0 19392 0 18741 0 229263 0 0 0 JEFF MILLER VP OF UNDERWRITING 138660 0 48720 0 648 0 19391 0 20654 0 228073 0 0 0 NANCE ORSBON VP - PROF RELATIONS 114700 0 102148 0 648 0 22004 0 11399 0 250899 0 0 0 CONNIE HALVERSON VP - PUBLIC RELATIONS 109350 0 38535 0 810 0 15463 0 27456 0 191614 0 0 0 GARY BJERRUM DDS DENTIST 149800 0 15000 0 729 0 16800 0 11399 0 193728 0 0 0 PART I, LINE 1A COMPANION TRAVEL IS WRITTEN INTO THE CEO'S EMPLOYMENT AGREEMENT. COMPANION TRAVEL COSTS ARE INCLUDED IN THE W-2 OF THE CEO AS TAXABLE WAGES. PART I, LINE 4B SCOTT JONES, PRESIDENT & CEO, PARTICIPATED IN A SUPPLEMENTAL EMPLOYEE RETIREMENT PLAN (SERP). THE AMOUNT OF THIS 2017 SERP CONTRIBUTION WAS $358,387 WHICH HE ALSO HAD TO INCLUDE IN WAGES AS HE IS FULLY VESTED IN THE SERP. THE SERP CONTRIBUTION IS INCLUDED IN SCHEDULE J, PART II, COLUMN (B)(II) FOR MR. JONES. JEFF FEIOCK DDS BOARD MEMBER 477551 INSURANCE REIMBURSEMENT 0 PAUL REZICH DDS BOARD MEMBER 183485 INSURANCE REIMBURSEMENT 0 MONTY BECHTOLD DDS BOARD MEMBER 295458 INSURANCE REIMBURSEMENT 0 GREG HANSON DDS BOARD MEMBER 148420 INSURANCE REIMBURSEMENT 0 PAT HERMANSON DDS BOARD MEMBER 323238 INSURANCE REIMBURSEMENT 0 ANLEE ROLA DDS BOARD MEMBER 452700 INSURANCE REIMBURSEMENT 0 THANE CRUMP DDS BOARD MEMBER 864807 INSURANCE REIMBURSEMENT 0 LEE GERTSEN SON OF BOARD MEMBER GREG GERTSEN 359104 INSURANCE REIMBURSEMENT 0 KIM SUGA DAUGTHER-IN-LAW OF BOARD MEMBER GREG GERTSEN 297486 INSURANCE REIMBURSEMENT 0 FORM 990, PART VI, SECTION A, LINE 1 THE EXECUTIVE COMMITTEE SHALL BE COMPOSED OF THE CHAIRMAN, VICE-CHAIRMAN, SECRETARY, TREASURER, AND SUCH OTHER MEMBERS AS THE BOARD DESIGNATES AND SHALL BE VESTED WITH SUCH POWERS AS THE BOARD OF DIRECTORS SHALL BY RESOLUTION DETERMINE. IT SHALL MAKE A WRITTEN REPORT OF ITS PROCEEDINGS AND ACTIONS AT THE NEXT SUCCEEDING MEETING OF THE BOARD OF DIRECTORS. THE CHAIRMAN SHALL BE THE CHAIRMAN OF THE EXECUTIVE COMMITTEE. FORM 990, PART VI, SECTION A, LINE 2 ELLEN LEE AND SCOTT JONES ARE DIRECTORS AT A COMMUNITY BANK. FORM 990, PART VI, SECTION A, LINE 6 THE MEMBERSHIP CONSISTS OF DENTISTS LICENSED IN SOUTH DAKOTA THAT PAY ONE-TIME MEMBERSHIP DUES. FORM 990, PART VI, SECTION A, LINE 7A ALL MEMBER DENTISTS IN ATTENDANCE AT THE ANNUAL MEETING HAVE ONE VOTE. FORM 990, PART VI, SECTION A, LINE 7B ALL MEMBER DENTISTS IN ATTENDANCE AT THE ANNUAL MEETING ARE ALLOWED ONE VOTE ON ALL AGENDA ITEMS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PROVIDED TO THE BOARD OF DIRECTORS AT THE MAY BOARD MEETING. A REVIEW OF THE FORM IS CONDUCTED BY THE CHAIR OF THE AUDIT AND FINANCE COMMITTEE. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS COMPLETE A CONFLICT OF INTEREST FORM ANNUALLY, IN MAY, AT THE REGULARLY SCHEDULED BOARD MEETING. EACH FORM IS READ AT THE FOLLOWING MEETING, WITH ACTION TAKEN AS NEEDED. ACTION MAY INCLUDE ABSTENTION FROM DISCUSSION AND VOTING AND POSSIBLE TERMINATION AS A BOARD MEMBER. FORM 990, PART VI, SECTION B, LINE 15 DELTA DENTAL OF SOUTH DAKOTA HAS A COMPENSATION COMMITTEE CHARTER, WHICH STATES THE PURPOSE OF THE COMPENSATION COMMITTEE IS TO REVIEW AND REPORT TO THE BOARD ON COMPENSATION AND PERSONNEL POLICIES, PROGRAMS AND PLANS AND TO APPROVE EMPLOYEE COMPENSATION AND BENEFIT PLANS. THE COMMITTEE CONSISTS OF THE BOARD CHAIR, VICE-CHAIR, AND AT LEAST TWO OTHER BOARD MEMBERS. COMMITTEE MEMBERS ARE APPOINTED TO ANNUAL TERMS AND MAY BE REAPPOINTED TO UNLIMITED CONSECUTIVE TERMS. THE COMMITTEE ANNUALLY REVIEWS THE CEO'S PERFORMANCE AND DETERMINES SALARY ADJUSTMENTS AND INCENTIVE PAYMENTS FOR THE CEO, ENSURING COMPLIANCE WITH THE IRS "REBUTTABLE PRESUMPTION" SAFETY ZONE FOR EXECUTIVE COMPENSATION MATTERS. THE COMMITTEE ALSO REVIEWS THE CEO'S RECOMMENDATIONS AS TO SALARY ADJUSTMENTS AND INCENTIVE PAYMENTS FOR EXECUTIVE STAFF, ENSURING COMPENSATION WITHIN THE RANGES OF THE EXECUTIVE COMPENSATION PHILOSOPHY. FORM 990, PART VI, SECTION C, LINE 19 ALL DOCUMENTS AND POLICIES ARE AVAILABLE UPON REQUEST. DELTA DENTAL OF SOUTH DAKOTA FOUNDATION PO BOX 1157 PIERRE SD 57501 911776857 ACCESS TO DENTAL CARE SD 501(C)(3) LINE 12C, III-FI DELTA DENTAL OF SOUTH DAKOTA 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 DELTA DENTAL OF SOUTH DAKOTA FOUNDATION B 2873661 CASH DELTA DENTAL OF SOUTH DAKOTA FOUNDATION O 2333500 CASH