2014-05-28T08:16:13-05:00 2013-12-31 450250958 EIDE BAILLY LLP 200 EAST 10TH ST PO BOX 5125 SIOUX FALLS SD 571175125 990 2013-01-01 460309258 DELTA DENTAL PLAN OF SOUTH DAKOTA DELT 6052247345 PO BOX 1157 PIERRE SD 57501 SCOTT JONES PRESIDENT & CEO 6052247345 2014-04-24 1 LAURIE HANSON P00851848 6053391999 2014-04-24 2013 2015-11-30 17:44:51Z SCOTT JONES PO BOX 1157 PIERRE SD 57501 112997319 0 X WWW.DELTADENTALSD.COM X 1963 SD DELTA DENTAL OF SOUTH DAKOTA IS DEDICATED TO ADVANCING AND PROMOTING THE IMPROVEMENT OF ORAL HEALTH. 15 15 78 0 2047020 0 0 0 91892462 99027615 879684 2531287 1377053 2031614 94149199 103590516 2315480 2576724 0 0 4438698 4309655 0 0 0 86516073 94220092 93270251 101106471 878948 2484045 41192992 46398157 8040647 11338510 33152345 35059647 DELTA DENTAL OF SOUTH DAKOTA IS DEDICATED TO ADVANCING AND PROMOTING THE IMPROVEMENT OF ORAL HEALTH. 0 0 91532788 2576724 99027615 DELTA DENTAL PAID THROUGH ITS CONTRACTS WITH INDEPENDENT DENTISTS 499,345 CLAIMS FOR DENTAL BENEFIT SERVICES FOR APPROXIMATELY 233,544 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 PHILANTHROPIC FUND, A 501(C)(3) CHARITABLE ORGANIZATION, $2,223,897 TO PROMOTE THE IMPROVEMENT OF ORAL HEALTH. 91532788 0 0 0 0 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 0 0 0 0 0 0 1 1 1 0 1 3330 0 1 78 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 PO BOX 1157 PIERRE SD 57501 DALE GIBSON DDS CHAIR 2.00 1.00 X X 12000 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 5700 0 0 JOHN CLAUSEN TREASURER 2.00 1.00 X X 11700 0 0 MONTY BECHTOLD DDS DIRECTOR 1.00 1.00 X 5500 0 0 STEVE CULHANE DIRECTOR 1.00 0.00 X 6500 0 0 JEFF FEIOCK DDS DIRECTOR 1.00 0.00 X 5500 0 0 G VERNE GOODSELL DIRECTOR 1.00 0.00 X 7000 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 6000 0 0 ELLEN LEE DIRECTOR 1.00 1.00 X 6500 0 0 ANLEE ROLA DDS DIRECTOR 1.00 0.00 X 5000 0 0 JIM RUSSELL DIRECTOR 1.00 0.00 X 7100 0 0 RYAN VAN LAECKEN DDS DIRECTOR (THRU MAY 2013) 1.00 0.00 X 3000 0 0 THANE CRUMP DDS DIRECTOR (AS OF MAY 2013) 1.00 1.00 X 2500 0 0 SCOTT JONES PRESIDENT & CEO 40.00 1.00 X 586060 0 301911 KIRBY SCOTT VICE PRESIDENT-FINANCE 40.00 0.00 X 168752 0 23934 GENE TETZLAFF VP - INFO TECHNICIAN 40.00 0.00 X 156556 0 32702 MICK HECKENLAIBLE VP - OPERATIONS 40.00 0.00 X 166248 0 33661 JEFF MILLER VP - UNDERWRITING 40.00 0.00 X 162436 0 33296 NANCE ORSBON VP - PROF RTNS 40.00 0.00 X 130770 0 25659 CONNIE HALVERSON VP - PUBLIC RELATIONS 40.00 0.00 X 125115 0 29564 GARY BJERRUM DENTIST 40.00 0.00 X 140409 0 26241 CARRIE MIKKONEN PROGRAM MANAGER 40.00 0.00 X 101186 0 17115 1841032 0 524083 9 0 1 0 0 PREMIUM EARNED 812900 98685671 98685671 MISCELLANEOUS 900099 341944 341944 99027615 947451 947451 35630 51036 -15406 -15406 -15406 10939603 9355767 1583836 1583836 1583836 MANAGEMENT SERVICE FEES 541610 2047020 2047020 2047020 103590516 99027615 2047020 2515881 2576724 2576724 1769056 1769056 1440991 1440991 532410 532410 366751 366751 200447 200447 1985 1985 48428 48428 131279 131279 230944 230944 395767 395767 14948 14948 55560 55560 69566 69566 206838 206838 367257 367257 62798 62798 CLAIMS INCURRED 88956064 88956064 MANAGEMENT SERVICE EXPE 2047020 2047020 COMMISSIONS 886908 886908 PREMIUM TAXES 432078 432078 312652 312652 101106471 91532788 9573683 0 194433 2832 1959192 4584316 6618016 9550343 99914 109179 6689842 2067111 4707710 4622731 19201021 27291070 8155142 257564 237686 41192992 46398157 3508045 2804008 4532602 8534502 8040647 11338510 X 33152345 35059647 0 0 0 0 33152345 35059647 41192992 46398157 2484045 1110370 -1687113 0 X 0 1 X 1 1 1 397371 397371 4703961 1125471 3578490 1588510 941640 646870 4622731 UNPAID CLAIMS AND CLAIMS INCURRED BUT NOT REPORTED 3710000 UNPAID CLAIMS ADJUSTMENT EXPENSES 371000 COST PLUS GROUP DEPOSITS 74100 DEFERRED PREMIUMS 1102803 CHECKS OUTSTANDING 597256 SUPPLEMENTAL RETIREMENT PLAN LIABILITY 2679343 8534502 X 101594532 -2047020 -2047020 103641552 -51036 -51036 103590516 99110487 51036 51036 99059451 2047020 2047020 101106471 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, 2013, 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. IN ACCORDANCE WITH THE APPLICABLE STATUTE OF LIMITATIONS, THE COMPANY'S TAX RETURNS COULD BE AUDITED BY THE INTERNAL REVENUE SERVICE FOR THE YEARS ENDED DECEMBER 31, 2010 TO 2013. PART XI, LINE 2D - OTHER ADJUSTMENTS: EXPENSES RECORDED IN REVENUE ON FINANCIAL STATEMENTS -2,047,020. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL EXPENSES RECORDED IN EXPENSES ON FINANCIAL STATEMENTS -51,036. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES RECORDED IN EXPENSES ON FINANCIAL STATEMENTS 51,036. PART XII, LINE 4B - OTHER ADJUSTMENTS: EXPENSES RECORDED IN REVENUE ON FINANCIAL STATEMENTS 2,047,020. 0 DELTA DENTAL PHILANTHROPIC FUND 804 NORTH EUCLID SUITE 1 PIERRE SD 57501 911776857 501(C)(3) 2223897 PROMOTE DENTAL HEALTH IN SOUTH DAKOTA CAPITAL AREA UNITED WAY 221 SOUTH CENTRAL AVE PIERRE SD 57501 460403398 501(C)(3) 41009 DISTRIBUTING CHARITABLE DONATIONS SD VOICES FOR CHILDREN PO BOX 2196 SIOUX FALLS SD 57101 460425502 501(C)(3) 50000 TO IMPROVE LIVES OF SD CHILDREN SD DENTAL FOUNDATION PO BOX 1194 PIERRE SD 57501 460367045 501(C)(3) 150000 PROGRAM SUPPORT 4 0 X 1 1 X X X X X X 0 1 0 0 0 0 0 0 0 SCOTT JONES PRESIDENT & CEO 395200 0 190000 0 860 0 289264 0 12647 0 887971 0 0 0 KIRBY SCOTT VICE PRESIDENT-FINANCE 126000 0 42000 0 752 0 16800 0 7134 0 192686 0 0 0 GENE TETZLAFF VP - INFO TECHNICIAN 117000 0 38850 0 706 0 15585 0 17117 0 189258 0 0 0 MICK HECKENLAIBLE VP - OPERATIONS 120000 0 39900 0 6348 0 16544 0 17117 0 199909 0 0 0 JEFF MILLER VP - UNDERWRITING 120000 0 39480 0 2956 0 16179 0 17117 0 195732 0 0 0 NANCE ORSBON VP - PROF RTNS 98370 0 31752 0 648 0 13012 0 12647 0 156429 0 0 0 CONNIE HALVERSON VP - PUBLIC RELATIONS 93600 0 30870 0 645 0 12447 0 17117 0 154679 0 0 0 GARY BJERRUM DENTIST 127200 0 12480 0 729 0 13594 0 12647 0 166650 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. CONTRIBUTIONS ON SCOTT'S BEHALF TOTAL $263,764 FOR 2013. FORM 990, PART VI, SECTION A, LINE 2 ELLEN LEE AND SCOTT JONES HAVE A BUSINESS RELATIONSHIP. 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 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. DENTAL DENTAL PHILANTHROPIC FUND 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 PLAN OF SOUTH DAKOTA B 2223897 CASH DELTA DENTAL PLAN OF SOUTH DAKOTA O 2047020 CASH