2013-11-15T14:27:47-06:00 2012-12-31 381357951 PLANTE & MORAN PLLC 10 S RIVERSIDE PLAZA 9TH FLOOR CHICAGO IL 60606 990 2012-01-01 362612058 DELTA DENTAL OF ILLINOIS DELT 6307184700 111 SHUMAN BOULEVARD NAPERVILLE IL 60563 STACEY K BONN 6307184700 2013-11-14 1 DAVID LOWENTHAL P00378651 3122071040 2013-11-14 2012 2016-02-25 16:41:14Z BERNARD GLOSSY 111 SHUMAN BOULEVARD NAPERVILLE IL 60563 621293518 0 X WWW.DELTADENTALIL.COM X 1967 IL IMPROVE THE ORAL HEALTH OF ILLINOIS RESIDENTS BY PROVIDING DENTAL BENEFITS & OTHER SERVICES. 11 8 165 0 489639 6003 0 0 536227452 612424130 1936432 1542658 27993 23948 538191877 613990736 675000 2000000 491320354 562857539 14356304 14832575 0 0 0 21600203 23645751 527951861 603335865 10240016 10654871 130235548 143246139 76139115 76298354 54096433 66947785 IMPROVE THE ORAL HEALTH OF ILLINOIS RESIDENTS BY PROVIDING DENTAL BENEFITS & OTHER SERVICES. 0 0 589604152 2000000 611934491 PROMOTE ORAL HEALTH THROUGH THE PROVISION OF DENTAL BENEFITS TO OVER 2,000,000 INDIVIDUALS. 589604152 0 0 0 1 0 0 0 0 0 1 0 0 0 1 1 0 1 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 67545 0 1 165 1 1 1 0 0 0 0 0 X 11 8 0 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X DELTA DENTAL OF ILLINOIS 6307184700 111 SHUMAN BOULEVARD NAPERVILLE IL 60563 DR RICHARD PERRY 5.00 X 33400 0 0 SHARON K HEATON 3.00 X 17700 0 0 CRAIG GRANNON 3.00 X 25975 0 0 DR ALAN JURGENS 3.00 X 13725 0 0 JOHN MAPLES 3.00 X 24075 0 0 PATRICIA HUNT-PREHEIM 3.00 X 18325 0 0 MICHAEL BUSSE 3.00 X 21375 0 0 NANCY COZZI 2.00 X 17925 0 0 DR RICHARD HESS 2.00 X 15350 0 0 DR DENNIS MANNING 2.00 X 14200 0 0 DR DAVID MILLER 2.00 X 13050 0 0 BERNARD GLOSSY 40.00 X 735717 0 37718 STACEY BONN 40.00 X 427893 0 38531 HAZEL FISHER-GABLE 40.00 X 358961 0 31855 KARYN GLOGOWSKI 40.00 X 306108 0 28435 MICHAEL WHITE 40.00 X 229297 0 24884 TERRI BON 40.00 X 222551 0 38182 DR KATINA SPADONI-MORELLI 40.00 X 193767 0 33388 SAMUEL HART 40.00 X 167768 0 29587 THOMAS GEARY 40.00 X 165932 0 34859 LINDA NASTI 40.00 X 157066 0 35783 TERRY MADDOX 40.00 X 151709 0 34941 THOMAS COLGAN 0.00 X 244309 0 7204 IRENE VASQUEZ 0.00 X 164789 0 4323 STEPHEN RETZSCH 0.00 X 150612 0 21912 THERESA MARSHALL 0.00 X 141262 0 30896 4032841 0 432498 25 1 1 0 ADVANTECH INC 2801 HOVER ROAD STEVENS POINT WI 54481 IT SYSTEM MAINTENANCE 3148588 EMDEON BUSINESS SERVICES 3183 RIDER TRAIL SOUTH EARTH CITY MO 63045 INVOICE AND CLAIMS PRINTING 2242570 THE MEYOCKS GROUP 6800 LAKE DRIVE WEST DES MOINES IA 50266 ADVERTISING AND MARKETING 891048 RICHARDS GRAPHIC COMMUNICATIONS 2700 VAN BUREN ST BELLWOOD IL 60104 COMMERCIAL PRINTER 573375 RYAN COMPANIES US INC 50 S TENTH STREET MINNEAPOLIS MN 55403 BUILDING MANAGER 555415 16 PREMIUMS 524114 611934491 611934491 BUILDING 531190 489639 489639 612424130 1499864 1499864 7345576 7302782 42794 42794 42794 OTHER INCOME 900099 23948 23948 23948 613990736 611934491 489639 1566606 2000000 2000000 562857539 562857539 4250239 396266 3853973 6626706 5119754 1506952 804649 398321 406328 887969 499134 388835 2263012 1473599 789413 199193 199193 120481 120481 162525 162525 1433169 395288 1037881 1279959 184464 1095495 673763 624287 49476 4000247 3940827 59420 365541 365541 179635 63842 115793 104596 46054 58542 470366 470366 1080005 114326 965679 319662 319662 BROKER COMMISSIONS 8187524 8187524 PRINTING & PUBLICATIONS 2536649 2073943 462706 INSURANCE DEPT. FEES 768885 697958 70927 BANK FEES 328081 328081 1435470 531026 904444 603335865 589604152 13731713 0 1845055 3739631 54115397 62918580 1156181 774897 20933877 2710062 19197777 18223815 48112936 51943550 5563448 5376099 244754 269567 130235548 143246139 11394140 12968238 4256776 3348880 10178945 5865108 50309254 54116128 76139115 76298354 X 0 0 0 0 54096433 66947785 54096433 66947785 130235548 143246139 10654871 2196481 0 X 0 1 X 1 0 0 1 0 3096941 3096941 16066877 1681576 14385301 179015 95058 83957 1591044 933428 657616 18223815 UNPAID CLAIMS AND CLAIMS ADJUSTMENT EXPENSE 8148000 SELF-INSURED UNPAID CLAIMS 45968128 54116128 X 613338572 0 613338572 162525 489639 652164 613990736 602683701 0 602683701 162525 489639 652164 603335865 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: THE COMPANY'S APPLICATION OF GAAP REGARDING UNCERTAIN TAX POSITIONS HAD NO EFFECT ON ITS FINANCIAL POSITION AS MANAGEMENT BELIEVES THE COMPANY HAS NO MATERIAL UNRECOGNIZED INCOME TAX BENEFITS. THE COMPANY WOULD ACCOUNT FOR ANY POTENTIAL INTEREST OR PENALTIES RELATED TO POSSIBLE FUTURE LIABILITIES FOR UNRECOGNIZED INCOME TAX BENEFITS AS INCOME TAX EXPENSE. THE COMPANY IS NO LONGER SUBJECT TO EXAMINATION BY TAX AUTHORITIES FOR FEDERAL, STATE, OR LOCAL INCOME TAXES FOR PERIODS BEFORE 2009. PART XI, LINE 4B - OTHER ADJUSTMENTS: RENTAL INCOME REPORTED ON PART VII 489,639. PART XII, LINE 4B - OTHER ADJUSTMENTS: RENTAL INCOME REPORTED ON PART VII 489,639. 1 DELTA DENTAL OF ILLINOIS FOUNDATION 111 SHULMAN BLVD NAPERVILLE IL 60563 262700504 501(C)3 2000000 PROMOTE ORAL HEALTH OF THE RESIDENTS OF ILLINOIS 1 0 PROCEDURE FOR MONITORING GRANTS IN THE U.S.: PART I, LINE 2: SCHEDULE I, PART I, LINE 2: 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 X X 1 1 X X X X X 1 0 0 0 0 0 0 0 0 BERNARD GLOSSY 447120 0 194400 0 94197 0 0 0 37718 0 773435 0 0 0 STACEY BONN 300000 0 103125 0 24768 0 0 0 38531 0 466424 0 0 0 HAZEL FISHER-GABLE 240875 0 97555 0 20531 0 0 0 31855 0 390816 0 0 0 KARYN GLOGOWSKI 180000 0 122506 0 3602 0 0 0 28435 0 334543 0 0 0 MICHAEL WHITE 160000 0 56250 0 13047 0 0 0 24884 0 254181 0 0 0 TERRI BON 159025 0 62435 0 1091 0 0 0 38182 0 260733 0 0 0 DR KATINA SPADONI-MORELLI 159787 0 26434 0 7546 0 0 0 33388 0 227155 0 0 0 SAMUEL HART 154808 0 12329 0 631 0 0 0 29587 0 197355 0 0 0 THOMAS GEARY 79231 0 86646 0 55 0 0 0 34859 0 200791 0 0 0 LINDA NASTI 75000 0 78503 0 3563 0 0 0 35783 0 192849 0 0 0 TERRY MADDOX 120470 0 28125 0 3114 0 0 0 34941 0 186650 0 0 0 THOMAS COLGAN 0 0 0 0 244309 0 0 0 7204 0 251513 0 0 0 IRENE VASQUEZ 0 0 0 0 164789 0 0 0 4323 0 169112 0 0 0 STEPHEN RETZSCH 60472 0 84715 0 5425 0 0 0 21912 0 172524 0 0 0 THERESA MARSHALL 65060 0 73400 0 2802 0 0 0 30896 0 172158 0 0 0 PART I, LINE 1A OFFICERS ARE ALLOWED TO TRAVEL FIRST CLASS WHEN TRAVELING TO ORGANIZATIONAL EVENTS WHERE FLIGHTS ARE OVER 2 HOURS AND THE BENEFIT IS CONSIDERED A TAXABLE FRINGE BENEFIT. THE OFFICERS OF THE ORGANIZATION ARE REIMBURSED FOR HEALTH CLUB MEMBERSHIP DUES UP TO $100 PER MONTH PER COMPANY POLICY. IN ADDITION, WHEN TRAVELING TO CERTAIN ORGANIZATIONAL EVENTS, OFFICERS AND DIRECTORS ARE REIMBURSED FOR THEIR COMPANION'S TRAVEL EXPENSES AS A TAXABLE BENEFIT. PART I, LINE 4A THOMAS COLGAN, SVP OF MARKETING, RECEIVED SEVERANCE OF $244,309. IRENE VAZQUEZ, SVP OF OPERATIONS, RECEIVED SEVERANCE OF $164,789. TRUASSURE SUBSIDIARY 127441 SALE OF INSURANCE PRODUCTS BY TRUASSURE TO DELTA DENTAL OF ILLINOIS. 0 DR ALAN JURGENS THROUGH JURGENS AN DIRECTOR 303695 PAYMENTS TO DENTAL PRACTICE FOR DENTAL SERVICES PROVIDED UNDER DENTAL INSURANCE POLICY. 0 SCHEDULE L PART V RELATIONSHIP BETWEEN INTERESTED PERSON AND THE ORGANZIATION BERNARD GLOSSY, HAZEL FISHER-GABLE, AND STACEY BONN ARE OFFICERS/KEY EMPLOYEES IN BOTH DELTA DENTAL OF ILLINOIS AND TRUASSURE INSURANCE COMPANY. DR. RICHARD PERRY, MR. JOHN MAPLES,DR. FRANK MAGGIO, MS. SHARON HEATON ,AND MS. PATRICIA HUNT-PREHEIM ARE DIRECTORS IN BOTH DELTA DENTAL OF ILLINOIS AND TRUASSURE INSURANCE COMPANY. FORM 990, PART VI, SECTION A, LINE 4 THE COMPANY AMENDED THE BY-LAWS SUCH THAT THE PUBLIC DIRECTORS NO LONGER HAVE TO BE REPRESENTATIVES OF THE COMPANY'S GROUP SUBSCRIBERS OR RESIDENTS OF THE STATE OF ILLINOIS. ADDITIONALLY, THE COMPANY'S BOARD OF DIRECTORS NEED ONLY TO BE COMPROMISED OF AT LEAST ONE THIRD (RATHER THAN A MAJORITY) OF DENTAL DIRECTORS. FORM 990, PART VI, SECTION A, LINE 6 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 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 PLEASE SEE THE RESPONSE FOR ITEM 7A. FORM 990, PART VI, SECTION B, LINE 11 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 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 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 CHIEF LEGAL OFFICER OF THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 15 CEO 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 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 TO THE BOARD FOR APPROVAL. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE AVAILABLE THROUGH APPLICABLE GOVERNMENTAL AGENCIES; THE CONFLICT OF INTEREST POLICY IS AVAILABLE UPON WRITTEN REQUEST TO THE ORGANIZATION. DELTA DENTAL OF ILLINOIS FOUNDATION 111 SHULMAN BLVD NAPERVILLE IL 60563 262700504 PROMOTE ORAL HEALTH OF THE RESIDENTS OF ILLINOIS IL 501(C)(3) LINE 7 1 TRUASSURE INSURANCE COMPANY 111 SHUMAN BLVD NAPERVILLE IL 60563 363757528 GROUP LIFE AND HEALTH INSURANCE IL C -187349 5890756 1.00000 1 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 0 1 1 1 TRUASSURE INSURANCE COMPANY M 127441 MAINTAINED RECORDS AT FMV TRUASSURE INSURANCE COMPANY Q 81179 MAINTAINED RECORDS AT FMV TRUASSURE INSURANCE COMPANY R 3139824 MAINTAINED RECORDS AT FMV TRUASSURE INSURANCE COMPANY S 453216 MAINTAINED RECORDS AT FMV DELTA DENTAL OF ILLINOIS FOUNDATION B 2000000 MAINTAINED RECORDS AT FMV