2016-11-15T14:31:08-06:00 2015-12-31 PRICEWATERHOUSECOOPERS LLP 101 SEAPORT BLVD BOSTON MA 02210 990 2015-01-01 208530788 Hamden Assurance Risk Retention Group Inc % DANIEL JANTZEN HAMD 6036531155 30 Main Street Suite 330 Burlington VT 05401 DANIEL JANTZEN CFO 6036505634 2016-11-15 Paul Tanis P01441612 6175305000 2015 2017-02-10 21:41:12Z DANIEL JANTZEN One Medical Center Drive Lebanon NH 03756 1164741 false X N/A X 2007 VT See Attachment 1 7 1 0 1 0 0 0 625259 575638 10345 14638 0 0 635604 590276 0 0 0 0 0 0 0 0 0 598242 494633 598242 494633 37362 95643 88377638 94887313 86699040 94120569 1678598 766744 X TO BENEFIT, TO PERFORM THE FUNCTIONS OF, AND TO CARRY OUT THE PURPOSES OF THE CHARITABLE CLASS OF BENEFICIARIES, THROUGH THE PROVISION OF SELF-INSURANCE COVERAGE AND OTHER SERVICES THAT RISK RETENTION GROUPS ARE PERMITTED TO PROVIDE UNDER THE APPLICABLE FEDERAL AND STATE LAW; TO ACQUIRE, ESTABLISH, RETAIN AND MAINTAIN A FUND OR FUNDS TO BE HELD, INVESTED AND USED EXCLUSIVELY FOR THE FOREGOING PURPOSES. false false 402831 575638 Hamden Assurance Risk Retention Group, Inc. (Hamden) was incorporated on February 28, 2007, under the laws of the State of Vermont by its Class A members: Dartmouth-Hitchcock Medical Center, Dartmouth-Hitchcock Clinic, Mary Hitchcock Memorial Hospital and the Trustees of Dartmouth College. Commencing operations on October 1, 2007, Hamden writes medical professional and general liability coverage for its members (insureds) which are also the owners. Insurance coverage is provided through a primary and an excess policy. 402831 true false false false false false false false false false false false false true true false true true false false true false false false false false false false false true false false false false false false false false false false false false false true true true false false true 4 0 true 0 false false false false false false false false false false X 7 1 true false false false true true true true true false false true true true true true false false false false X DANIEL JANTZEN 6036505634 ONE MEDICAL CENTER Lebanon NH 03756 Daniel P Jantzen CPA Vice President 1.0 60.0 X X 0 676831 151921 Lawrence J Dacey MD MS President 1.0 40.3 X X 0 0 188491 Robin F Kilfeather-Mackey CPA Vice President & Treasurer 1.0 60.01 X X 0 550797 175125 Thomas A Colacchio MD Chairman 1.0 40.0 X X 0 1021525 81611 Robert M Gagliardi Director 1.0 0.0 X 0 0 0 Paul F Greeley Director 1.0 40.0 X 0 203658 17737 John Kacavas JD Secretary Eff 9/9/15 1.0 60.0 X X 0 242425 29942 Jeanine Arden-Ornt Secretary End 3/2/2015 1.0 25.0 X X 0 213499 0 Randall L Wachsmann Assistant Secretary 1.0 0.0 X 0 0 0 0 2908735 644827 0 false true false 0 0 CEDING COMMISSIONS 524298 575638 575638 575638 14194 14194 0 0 0 0 0 574909 574465 444 444 444 0 0 0 0 590276 575638 14638 0 0 0 0 0 0 0 0 0 0 104605 83675 20930 11415 11415 48359 48359 0 0 5112 5112 0 0 613 613 41787 41787 0 0 150 150 0 0 0 0 0 0 ACTUARIAL FEES 170000 170000 PREMIUM TAX EXPENSE 101362 101362 LETTER OF CREDIT FEES 3492 3492 STATE FEES AND REG 1230 1230 6508 1135 5373 494633 402831 91802 0 0 0 524508 545267 0 0 31469562 42330403 0 0 0 0 0 0 0 0 251685 210239 0 2074342 2388117 0 0 0 0 0 0 54057541 49413287 88377638 94887313 234746 568015 0 0 327480 248158 0 0 0 0 0 0 0 0 0 0 86136814 93304396 86699040 94120569 X 0 0 1050000 50000 628598 716744 1678598 766744 88377638 94887313 X 95643 -7497 -1000000 X false true X true false X X X 4 DARTMOUTH-HITCHCOCK CLINIC 222519596 9 true 0 0 MARY HITCHCOCK MEMORIAL HOSPITAL 020222140 3 true 0 0 TRUSTEES OF DARTMOUTH COLLEGE 020222111 2 true 0 0 DARTMOUTH-HITCHCOCK MEDICAL CENTER 222715483 9 true 0 0 4 0 0 true true false false false false false false false false false false false false false false false true false Organizations without IRS determination under 509(a)(1) or (2) Form 990, Schedule A, Part IV, Section A, Line 2 THE LIST OF SPECIFIED SUPPORTED ORGANIZATIONS OF HAMDEN ASSURANCE RISK RETENTION GROUP, INC. INCLUDES DARTMOUTH-HITCHCOCK MEDICAL CENTER, WHICH ITSELF IS A SUPPORTING ORGANIZATION DESCRIBED IN SECTION 509(A)(3) OF THE INTERNAL REVENUE CODE. AS DESCRIBED TO THE IRS IN HRRG'S FORM 1023 EXEMPTION APPLICATION, DHMC WAS INCLUDED AS A CLASS A MEMBER OF HRRG (AND, THUS, A SPECIFIED SUPPORTED ORGANIZATION) PRIMARILY BASED ON ITS POTENTIAL DESIGNATION AS A DEFENDANT IN ANY LITIGATION AGAINST HRRGS OTHER SPECIFIED SUPPORTED ORGANIZATIONS. FROM THE TIME OF FILING ITS FORM 1023, UP TO AND INCLUDING THE FILING OF THIS FORM 990, THE NEED FOR HRRG TO OPERATE FOR THE BENEFIT OF DHMC OR ANY OTHER SECTION 509(A)(3) ORGANIZATION WAS AND IS A REMOTE CONTINGENCY WITHIN THE MEANING OF TREASURY REGULATION SECTION 1.509(A)-4(D)(4)(I)(B). ACCORDINGLY, HRRG MEETS THE REQUIREMENTS OF TREASURY REGULATION SECTION 1.509(A)-4(D)(2)(II). DEPOSIT ASSET 49410067 ACCRUED INTEREST 3220 49413287 0 DEPOSIT LIABILITY 50898214 PREMIUM TAXES PAYABLE 75778 DUE TO MEMBERS AND AFFILIATES 42330404 93304396 577666 -7497 -7497 585163 5113 5113 590276 489520 489520 5113 5113 494633 ASC 740 Footnote Form 990, Schedule D, Part X, Line 2 No ASC 740 footnote was included in the audited financial statements as there were no material uncertain tax positions at or since adoption. Central America and the Caribbean Program Services Insurance 3152647 3152647 3152647 false false false false false false Form 990, Schedule F, Part I, Column (f) The $3,152,647 reported under column (f) to Central America/Caribbean represents the amount accounted for within the balance sheet of the audited financial statements of the organization. true true false false false false false false false Daniel P Jantzen CPA Vice President 0 514015 0 0 0 162816 0 136497 0 15424 0 828752 0 0 Lawrence J Dacey MD MS President 0 0 0 0 0 0 0 178092 0 10399 0 188491 0 0 Robin F Kilfeather-Mackey CPA Vice President & Treasurer 0 513562 0 0 0 37235 0 154998 0 20127 0 725922 0 0 Thomas A Colacchio MD Chairman 0 932710 0 0 0 88815 0 64362 0 17249 0 1103136 0 0 Paul F Greeley Director 0 203042 0 0 0 616 0 16983 0 754 0 221395 0 0 John Kacavas JD Secretary Eff 9/9/15 0 242170 0 0 0 255 0 18978 0 10964 0 272367 0 0 Jeanine Arden-Ornt Secretary End 3/2/2015 0 213499 0 0 0 0 0 0 0 0 0 213499 0 0 Severance Payments Form 990, Schedule J, Part I, Line 4a Jeanine Arden-Ornt ended employment with a related organization, MHMH, on 6/30/2014. MHMH engaged the former employee on a consulting basis until 6/30/2015 to assist with Risk Management and Insurance Consulting Services. Schedule J, Part II, Column B(i) consists entirely of IRS Form 1099-Misc compensation. Supplemental Nonqualified Retirement Plan Form 990, Schedule J, Part I, Line 4b The following individuals received funds from a supplemental nonqualified retirement plan: Daniel Jantzen $75,081 Robin Kilfeather-Mackey $16,500 Thomas Colacchio $88,815 Terms and Conditions: An eligible employee is a participant in the Dartmouth-Hitchcock Retirement Plan and/or any prior pension arrangements sponsored by Dartmouth-Hitchcock (including a qualified defined benefit plan) who would be entitled to additional contributions or benefit accruals under the terms of the plans for the plan year, but are limited by IRC Section 401(A) and/or 415. For eligible employees, the employer will pay the eligible employee an amount determined by the employer each year to offset the amount of the reduction in the benefit accrual or contributions as a result of limitations imposed by IRC sections 401(A)(17) and/or 415. Mary Hitchcock Memorial Hospital and Dartmouth-Hitchcock Clinic, both related organizations, sponsor a split dollar life plan for certain long-term employees. The original objectives for offering these plans were to better enable MHMH to attract and retain quality executive personnel, improve the physicians' post-retirement life insurance benefits, and to replace an increasingly costly retiree life insurance program. The plan was frozen in 1998 and therefore no further costs of the individual employee insurance premiums have been funded by the organization. The number of participants and dollar value continues to dwindle as individuals retire/leave the organization. Business Relationships Form 990, Part VI, Section A, Line 2 Hamden Assurance Risk Retention Group is part of the Dartmouth-Hitchcock Health System, which owns for-profit subsidiaries that provide services and supports the mission of the organizations. As a result, some officers of HARRG may also be officers of related for-profits entities. Description of Organization's Delegation of Management Control Form 990, Part VI, Line 3 The Organization has a management agreement with AIG Management Services to provide day-to-day accounting and administrative services (such as legal and insurance registrations). The board retains all voting rights and decision making over the Organization. Description of Classes of Members or Stockholders Form 990, Part VI, Line 6 There are two classes of members: Class A Members and Class B Members. The initial Class A Members shall be Dartmouth-Hitchcock Medical Center, Dartmouth-Hitchcock Clinic, Mary Hitchcock Memorial Hospital, and the Trustees of Dartmouth College. Class B Members shall be entities affiliated with or related to the Class A Members. Description of Classes of Persons and the Nature of Their Rights Form 990, Part VI, Line 7a Each class A Member shall have full voting rights. The number of votes Each Class A Member Shall be entitled to cast on each matter submitted to a vote of the members shall be based on a ratio that one class A member's risk bears to risks all Class A members of the corporation as set forth in the Coporation's Bylaws, Predicated on either the class A member's first year premiums or deposits. Class B members shall, voting as a separate class, have the right to elect one Class B Director of the Corporation. Class B Members shall NOT have the right to vote on any other matters submitted to a vote of the Members, except as otherwise provided under Vermont law. Each class B Member shall have one vote for each matter on which the class B members are entitled to vote. In addition to approving board members,HRRG members must approve amendments to the bylaws, articles, and dissolution of the corporation. Descr Classes of Persons, Decisions Requiring Appr & Type of Voting Rights Form 990, Part VI, Line 7b The affairs of the Organization shall be managed by a Board of Directors consisting of at least three and no more than seven members of Dartmouth-Hitchcock Clinic, Mary Hitchcock Memorial Hospital, and the Trustees of Dartmouth College. The Class B Members shall, voting as a separate class, have the right to elect one Class B Director of the Organization. All additional members of the Board of Directors, if any shall be appointed by the Clinic, Hospital, and the Trustees of Dartmouth College. Governance Over Approval and Filing of 990 Form 990, Part VI, Line 11b An ad hoc committee including at least, but not limited to, the president and vice president, review the form before its filing and report to the board at their annual meeting. A copy of the full form 990 is given to the board before filing. Conflict of Interest Policy Enforcement Form 990, Part VI, Line 12c The Hamden Risk Retention Group's BOARD OF TRUSTEES APPROVED A POLICY CONCERNING A VOLUNTARY SELF-DISCLOSURE OF ANY POTENTIAL CONFLICT OF INTEREST. THE DARTMOUTH-HITCHCOCK OFFICE OF POLICY SUPPORT, COMPLIANCE AND AUDIT SERVICES CONDUCTS AN ANNUAL SURVEY OF ALL OFFICERS AND TRUSTEES AND PERFORMS OTHER PROCEDURES AS CONSIDERED NECESSARY TO REPORT ON COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY. THE COMPLIANCE AND AUDIT SERVICES DEPARTMENT THEN REPORTS TO EACH BOARD ANY POTENTIAL CONFLICTS FOR THEIR REVIEW. PER THE POLICY, ANY CONFLICTS, OR OTHERWISE PERCEIVED CONFLICTS, ARE REQUIRED TO BE ADDRESSED BY THE BOARD OF TRUSTEEES ON AN ONGOING BASIS. IN THE EVENT A CONFLICT ARISES, THE INDIVIDUAL MAY BE REMOVED FROM PARTICIPATING IN ANY DECISION MAKING REGARDING THE IDENTIFIED CONFLICT AND/OR ITS CORRESPONDING TRANSACTIONS. IF THE BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE THAT AN INTERESTED PERSON HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM SUCH PERSON ON THE BASIS FOR SUCH BELIEF AND AFFORD HIM/HER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. IF, AFTER HEARING THE RESPONSE OF THE INTERESTED PERSON AND MAKING SUCH FURTHER INVESTIGATION AS MAY BE WARRANTED IN THE CIRCUMSTANCES, THE BOARD OR COMMITTEE DETERMINES THAT SUCH PERSON HAS IN FACT FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. OFFICES & POSITIONS FOR WHICH PROCESS WAS USED, & YEAR UNDERTAKEN Form 990, Part VI, Section B, Line 15A & 15B Some of the organizations officers are compensated by Dartmouth-Hitchcock Clinic and Mary Hitchcock Memorial Hospital, both related and supported organizations of HRRG. Although paid by a related organization, the Compensation for the reported officers is evaluated by an independent third party firm for reasonableness and national data benchmarking. The DHC and MHMH Compensation Committee, along with Independent DHC and MHMH Trustees approved the final compensation in consideration with the independent third party firm's recommendations and suggestions. This process was contemporaneously documented and last undertaken in 2014. Compensation rates are determined by following guidelines of the compensation committee charter and philosophy documents and/or a formal review by compensation committee members of DHC and MHMH. Avail of Gov Docs, Conflict of Interest Policy, & Fin Stmts to Gen Public Form 990, Part VI, Line 19 The Organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Other Changes in Net Assets or Fund Balances Form 990, Part XI, Line 9 The Organization has obtained a permitted practice from the Vermont Department of Financial Regulation to include a $1,000,000 letter of credit for capitalization purposes as an asset within the presentation of the balance sheet. Generally accepted accounting principles within the United States do not allow for the presentation of letters of credit as assets. As a result, total assets and total net assets have been reduced by $1,000,000 at December 31, 2015 and 2014. Dartmouth-Hitchcock Clinic One Medical Center Drive Lebanon NH 03756 222519596 PHYSICIAN SVC NH 501(c)(3) 9 D-HH true Mary Hitchcock Memorial Hospital One Medical Center Drive Lebanon NH 03756 020222140 Hospital NH 501(c)(3) 3 D-HH true Trustees of Dartmouth College 37 Dewey Field Road Hanover NH 03755 222527266 Higher Educ. NH 501(c)(3) 2 NA false Dartmouth-Hitchcock Health One Medical Center Drive Lebanon NH 03756 264812335 PARENT ORG NH 501(c)(3) 7 NA false The Hitchcock Foundation One Medical Center Drive Lebanon NH 03756 020222139 HLTHCRE RSRCH NH 501(c)(3) 7 DHC true The New London Hospital Association Inc 273 County Rd New London NH 03257 020222171 Hospital NH 501(c)(3) 3 D-HH true Windsor Hospital Association 289 Country Road Windsor VT 05089 030183721 Hospital VT 501(C)(3) 3 D-HH true Mt Ascutney Hosp Cmmty Hlth Found 289 Country Road Windsor VT 05089 030300481 Foundation VT 501(c)(3) 3 WHA true Historic Homes of Runnemede 289 Country Road Windsor VT 05089 237396147 Healthcare VT 501(c)(3) 9 WHA true Cheshire Medical Center 580 Court Street Keene NH 03431 020354549 Hospital NH 501(c)(3) 3 D-HH true Cheshire Health Foundation 580 Court Street Keene NH 03431 020202220 SUPPORTNG ORG NH 501(C)(3) 11 TYPE I CMC true Dartmouth-Hitchcock Medical Center One Medical Center Drive Lebanon NH 03756 222715483 Supportng Org NH 501(c)(3) 11 TYPE I NA true Cheshire Health Services 580 Court Street Keene NH 03431 473379283 HEALTHCARE NH 501(c)(3) 3 CMC true Obnet Services LLC 1 Med Ctr Dr Lebanon NH 03756 043746287 Database Serv NH DHC D-H Master Inv Prog 1 Med Ctr Dr Lebanon NH 03756 020505863 Pooled Inv NH MHMH Keene Hlth Alliance 580 Court St Keene NH 03431 300179297 Healthcare NH NA One Care VT ACOLLC 111 COLCHESTER AVE Burlington VT 05401 455399218 Shared Saving VT NA New Eng Pharm Collab 1 Med Ctr Dr Lebanon NH 03756 263819035 Purchasing NH NA Pompanoosuc Investment Corporation One Medical Center Drive Lebanon NH 03756 020352330 Rl Estate Hld NH DHC C Corp true Hamden Assurance Company Ltd Canons Court 22 Victoria St HM EX Hamilton BD 202588083 Liab. Ins BD DHC C Corp true Hitchcock Health Connect One Medical Center Drive Lebanon NH 03756 800908979 Telehealth NH D-HH C corp true Kearsarge Community Services Inc 273 County Road New London NH 03257 020460136 Rl Estate Hld NH NLH C Corp true New London Medical Center East Inc 273 County Road New London NH 03257 020480857 Rl Estate Hld NH NLH C Corp true New London Physician Group Inc 273 County Road New London NH 03257 020494420 Physician Gro NH NLH Corp true Charit Remndr Unitrusts (5) One Medical Center Drive Lebanon NH 03756 Chart. Trust NH MHMH Trust true Keene Health Services 580 Court Street Keene NH 03431 020374997 Real Est Hldg NH CMC C Corp true Keene Health Realty 580 Court Street Keene NH 03431 020374998 Real Est Hldg NH CMC C Corp true Keene Health Enterprises 580 Court Street Keene NH 03431 020374999 Real Est Hldg NH CMC C Corp true false false false false false false false false false false false false false false false true true false Dartmouth Hitchcock Clinic Q 1394689 FMV Mary Hitchcock Memorial Hospital Q 3254274 FMV Hamden Assurance Company Ltd R 3152647 FMV