2016-09-26T09:46:56-05:00 2015-12-31 450250958 EIDE BAILLY LLP 200 EAST 10TH ST PO BOX 5125 SIOUX FALLS SD 571175125 990 2015-01-01 460309258 DELTA DENTAL PLAN OF SOUTH DAKOTA DELT 6052247345 PO BOX 1157 PIERRE SD 57501 SCOTT JONES PRESIDENT & CEO 6052247345 2016-09-20 1 LAURIE HANSON P00851848 6053391999 2016-09-20 2015 2017-02-10 21:41:12Z SCOTT JONES PO BOX 1157 PIERRE SD 57501 139191855 0 X WWW.DELTADENTALSD.COM X 1963 SD DELTA DENTAL PLAN OF SOUTH DAKOTA IS DEDICATED TO ADVANCING AND PROMOTING THE IMPROVEMENT OF ORAL HEALTH. 15 15 91 0 2087782 0 0 0 122355318 136730384 937616 334989 2158563 2076483 125451497 139141856 2847871 2145512 0 0 5172298 5681807 0 0 0 118185471 129863339 126205640 137690658 -754143 1451198 45852452 45512106 12938013 12523317 32914439 32988789 DELTA DENTAL PLAN OF SOUTH DAKOTA IS DEDICATED TO ADVANCING AND PROMOTING THE IMPROVEMENT OF ORAL HEALTH. 0 0 125941543 2145512 136730384 DELTA DENTAL PAID THROUGH ITS CONTRACTS WITH INDEPENDENT DENTISTS 562,839 CLAIMS FOR DENTAL BENEFIT SERVICES FOR APPROXIMATELY 272,462 INDIVIDUALS WITH GROUP PLANS, 26,000 INDIVIDUALS WITH DENTAL ACCIDENT PLANS, 112,000 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, $2,030,051 TO PROMOTE THE IMPROVEMENT OF ORAL HEALTH. 125941543 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 3465 0 1 91 1 1 1 0 0 0 0 0 X 15 15 1 0 0 0 1 1 1 1 0 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 11250 0 0 PAUL REZICH DDS VICE CHAIR 1.00 1.00 X X 6500 0 0 GREG GERTSEN DDS SECRETARY 1.00 0.00 X X 6900 0 0 JOHN CLAUSEN TREASURER 2.00 1.00 X X 10900 0 0 MONTY BECHTOLD DDS DIRECTOR 1.00 1.00 X 6500 0 0 STEVE CULHANE DIRECTOR 1.00 0.00 X 5500 0 0 JEFF FEIOCK DDS DIRECTOR 1.00 0.00 X 6500 0 0 G VERNE GOODSELL DIRECTOR 1.00 0.00 X 7600 0 0 GREG HANSON DDS DIRECTOR 1.00 0.00 X 6500 0 0 PAT HERMANSON DDS DIRECTOR 1.00 0.00 X 6500 0 0 MARY HITZEMANN DIRECTOR 1.00 0.00 X 7500 0 0 ELLEN LEE DIRECTOR 1.00 1.00 X 6500 0 0 ANLEE ROLA DDS DIRECTOR 1.00 1.00 X 5500 0 0 JIM RUSSELL DIRECTOR 1.00 0.00 X 7900 0 0 THANE CRUMP DDS DIRECTOR 1.00 1.00 X 6500 0 0 SCOTT JONES PRESIDENT & CEO 40.00 1.00 X 2919635 0 43593 KIRBY SCOTT VICE PRESIDENT OF FINANCE/CFO 40.00 1.00 X 180392 0 32140 GENE TETZLAFF VP - INFO TECHNICIAN 40.00 1.00 X 171166 0 43072 MICK HECKENLAIBLE VP OF OPERATIONS 40.00 1.00 X 181468 0 44394 JEFF MILLER VP OF UNDERWRITING 40.00 1.00 X 171510 0 43722 NANCE ORSBON VP - PROF RELATIONS 40.00 1.00 X 147138 0 43878 CONNIE HALVERSON VP - PUBLIC RELATIONS 20.00 20.00 X 132240 0 38718 GARY BJERRUM DDS DENTIST 0.00 40.00 X 148107 0 24965 CARRIE MIKKONEN PROGRAM MANAGER 0.00 40.00 X 114860 0 19447 SARA GREEN UNDERWRITING ANALYST 40.00 0.00 X 102549 0 26807 4377615 0 360736 11 0 1 0 0 PREMIUM EARNED 812900 136349525 136349525 MISCELLANEOUS 900099 380859 380859 136730384 334989 334989 38700 49999 -11299 -11299 -11299 MANAGEMENT SERVICE FEES 541610 2087782 2087782 2087782 139141856 136730384 2087782 323690 2145512 2145512 2013152 2013152 1546117 1546117 1202580 1202580 641410 641410 278548 278548 3901 3901 77421 77421 183473 183473 329027 329027 450103 450103 19512 19512 57890 57890 69914 69914 206132 206132 343686 343686 67317 67317 CLAIMS INCURRED 123796031 123796031 MANAGEMENT SERVICE EXPE 2087782 2087782 COMMISSIONS 1033100 1033100 PREMIUM TAXES 700824 700824 437226 437226 137690658 125941543 11749115 0 8555 5071 3316289 4075184 8107044 9260917 109674 128382 6883033 2840602 4368978 4042431 29645373 27102495 671821 296539 225805 45852452 45512106 3088186 3425848 9849827 9097469 12938013 12523317 X 32914439 32988789 0 0 0 0 32914439 32988789 45852452 45512106 1451198 -1376848 0 X 0 1 X 1 0 397371 397371 4715351 1399730 3315621 1770311 1440872 329439 4042431 UNPAID CLAIMS AND CLAIMS INCURRED BUT NOT REPORTED 5023646 UNPAID CLAIMS ADJUSTMENT EXPENSES 452000 COST PLUS GROUP DEPOSITS 74100 DEFERRED PREMIUMS 1305924 SUPPLEMENTAL RETIREMENT PLAN LIABILITY 2241799 9097469 X 137104073 -2087782 -2087782 139191855 -49999 -49999 139141856 135652875 49999 49999 135602876 2087782 2087782 137690658 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, 2015, 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 -2,087,782. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES RECORDED IN EXPENSES ON FINANCIAL STATEMENTS -49,999. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES RECORDED IN EXPENSES ON FINANCIAL STATEMENTS 49,999. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES RECORDED IN REVENUE ON FINANCIAL STATEMENTS 2,087,782. 0 DELTA DENTAL OF SOUTH DAKOTA FOUNDATION 804 NORTH EUCLID SUITE 1 PIERRE SD 57501 911776857 501(C)(3) 2030051 PROMOTE DENTAL HEALTH IN SOUTH DAKOTA CAPITAL AREA UNITED WAY 221 SOUTH CENTRAL AVE PIERRE SD 57501 460403398 501(C)(3) 45295 DISTRIBUTING CHARITABLE DONATIONS SD VOICES FOR CHILDREN PO BOX 2196 SIOUX FALLS SD 57101 460425502 501(C)(3) 25000 TO IMPROVE LIVES OF SD CHILDREN 3 0 X 1 1 X X X X X X 0 1 0 0 0 0 0 0 0 SCOTT JONES PRESIDENT & CEO 2348487 0 571148 0 0 0 26000 0 17593 0 2963228 0 1926490 0 KIRBY SCOTT VICE PRESIDENT OF FINANCE/CFO 133650 0 45990 0 752 0 21987 0 10153 0 212532 0 0 0 GENE TETZLAFF VP - INFO TECHNICIAN 127200 0 43260 0 706 0 20865 0 22207 0 214238 0 0 0 MICK HECKENLAIBLE VP OF OPERATIONS 130200 0 44310 0 6958 0 21973 0 22421 0 225862 0 0 0 JEFF MILLER VP OF UNDERWRITING 126552 0 44310 0 648 0 21655 0 22067 0 215232 0 0 0 NANCE ORSBON VP - PROF RELATIONS 111420 0 35070 0 648 0 32830 0 11048 0 191016 0 0 0 CONNIE HALVERSON VP - PUBLIC RELATIONS 97152 0 34440 0 648 0 16635 0 22083 0 170958 0 0 0 GARY BJERRUM DDS DENTIST 133938 0 13440 0 729 0 14936 0 10029 0 173072 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). COMPENSATION REPORTED AS DEFERRED IN PRIOR YEAR FORM 990'S WAS A TOTAL OF $1,926,490. BECAUSE SCOTT JONES VESTED IN MARCH OF 2015, HE WAS REQUIRED TO CATCH UP THE DEFERRED AMOUNTS FROM PRIOR YEARS. HIS SERP AMOUNT OF CATCH UP INCOME AMOUNTED TO $1,926,490, WHICH WAS ALL DEFERRED FROM PRIOR YEARS. THE AMOUNT OF HIS 2015 SERP CONTRIBUTION WAS $251,262 WHICH HE ALSO HAD TO INCLUDE IN WAGES AS HE IS FULLY VESTED IN THE SERP. JEFF FEIOCK DDS BOARD MEMBER 329584 INSURANCE REIMBURSEMENTS 0 PAUL REZICH DDS BOARD MEMBER 187848 INSURANCE REIMBURSEMENT 0 MONTY BECHTOLD DDS BOARD MEMBER 267867 INSURANCE REIMBURSEMENT 0 GREG HANSON DDS BOARD MEMBER 263607 INSURANCE REIMBURSEMENT 0 PAT HERMANSON DDS BOARD MEMBER 291743 INSURANCE REIMBURSEMENT 0 ANLEE ROLA DDS BOARD MEMBER 459913 INSURANCE REIMBURSEMENT 0 THANE CRUMP DDS BOARD MEMBER 772149 INSURANCE REIMBURSEMENT 0 FORM 990, PART VI, SECTION A, LINE 2 ELLEN LEE AND SCOTT JONES ARE BOTH DIRECTORS OF 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 A, LINE 8B THE ORGANIZATION DOES NOT HAVE COMMITTEES WITH BROAD AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BOARD. FORM 990, PART VI, SECTION B, LINE 11 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 PLAN 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 11B, II DELTA DENTAL PLAN 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 2030051 CASH DELTA DENTAL OF SOUTH DAKOTA FOUNDATION O 2087782 CASH