2013-10-11T16:18:41-05:00 2012-12-31 830331229 MCGEE HEARNE & PAIZ LLP P O BOX 1088 CHEYENNE WY 82003 990 2012-01-01 830209667 DELTA DENTAL PLAN OF WYOMING DELT 3076323313 6234 YELLOWSTONE RD CHEYENNE WY 82009 KERRY HALL 3076323313 2013-10-08 1 RUSSELL E HAY P00028728 3076342151 2012 2016-02-25 16:41:14Z DELTA DENTAL OF WYOMING KERRY HALL 6234 YELLOWSTONE RD CHEYENNE WY 82009 32479138 0 X N/A X 1968 WY TO BE THE LEADING WYOMING PROVIDER OF HIGH QUALITY DENTAL CARE PROGRAMS WHICH ARE RESPONSIVE TO SUBSCRIBERS, PURCHASERS AND PARTICIPATING DENTISTS ALIKE WITH THE GOAL OF MAKING AFFORDABLE DENTAL CARE AVAILABLE TO ALL WYOMING EMPLOYEES. 13 6 8 0 0 0 0 0 28721931 30669313 645710 363501 -12984 0 29354657 31032814 0 0 0 0 819554 899949 0 0 0 27261041 29242364 28080595 30142313 1274062 890501 10428867 11911873 3322345 3662016 7106522 8249857 TO BE THE LEADING WYOMING PROVIDER OF HIGH QUALITY DENTAL CARE PROGRAMS WHICH ARE RESPONSIVE TO SUBSCRIBERS, PURCHASERS AND PARTICIPATING DENTISTS ALIKE WITH THE GOAL OF MAKING AFFORDABLE DENTAL CARE AVAILABLE TO ALL WYOMING EMPLOYEES. 0 0 29250945 30669313 PROVIDE PROCESSING OF DENTAL PLANS, PAYMENTS AND CLAIMS FOR PURCHASERS, SUBSCRIBERS AND PARTICIPATING DENTISTS WITH THE GOAL OF MAKING AFFORDABLE DENTAL CARE AVAILABLE TO ALL WYOMING EMPLOYEES. 29250945 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 0 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 1265 0 1 8 1 0 0 0 0 0 0 0 0 1 0 X 13 6 0 0 0 0 1 1 1 1 1 1 0 1 1 1 1 1 1 1 0 0 X KERRY HALL 3076323313 6234 YELLOWSTONE RD CHEYENNE WY 82009 DR BRUCE HOLWELL 1.00 X X 1834 0 0 DR JAMES GILMAN 1.00 X X 1552 0 0 DR ROBERT TYRRELL 1.00 X X 1710 0 0 BRUCE HINCHEY 1.00 X X 1372 0 1452 DR SCOTT HOUFEK 1.00 X 1200 0 0 DR BYRON KILLPACK 1.00 X 772 0 0 ROXANNE OSTLUND 1.00 X 1496 0 1452 BOB PALMER 1.00 X 1426 0 0 DR ROY PAULSON 1.00 X 1422 0 0 DR BILL GERN 1.00 X 1064 0 0 ROD CHISHOLM 1.00 X 1260 0 0 RAY BISHOP 1.00 X 788 0 0 DR ED CLARK 1.00 X 4222 0 0 KERRY HALL 40.00 X 202353 0 100129 STACY ZASTOUPIL 40.00 X 101153 0 27978 DR EARL KINCHELOE 5.00 X 61078 0 1452 JEFF MARSH 1.00 X 804 0 1452 385506 0 133915 2 0 1 0 DELTA DENTAL OF SOUTH DAKOTA 720 N EUCLID AVE PIERRE SD 57501 CLAIMS PROCESSING & SUPPLIES 462208 1 DENTAL PREMIUMS & ADMI 524114 30669313 30669313 30669313 248380 248380 1561445 1446324 115121 115121 115121 31032814 30669313 0 363501 385506 206246 179260 276103 147715 128388 110141 58925 51216 83544 44696 38848 44655 23891 20764 3809 857 2952 27410 6167 21243 29088 29088 112091 14011 98080 73730 38708 35022 54609 20206 34403 23327 6648 16679 69224 19729 49495 11868 4628 7240 13474 4716 8758 DENTAL CLAIMS PAID 27181399 27181399 COMMISSIONS 617548 617548 COMPUTER - CLAIMS 354596 320909 33687 POSTAGE & SHIPPING 125968 90697 35271 544223 443249 100974 30142313 29250945 891368 0 1675139 1611715 334559 309288 1879009 1978157 33938 28742 218046 146923 21270 71123 4415858 5764116 2054547 2126985 14547 21747 10428867 11911873 955173 1307701 255248 278346 2111924 2075969 3322345 3662016 X 7106522 8249857 7106522 8249857 10428867 11911873 890501 252834 0 X X 0 1 X 1 0 56078 4673 51405 138189 120765 17424 23779 21485 2294 71123 INVESTMENT IN LIFE INSURANCE CONTRACT 1400333 F CERTIFICATE OF DEPOSIT 726652 F 2126985 DEFERRED COMPENSATION PAYABLE 906946 MEMBER REPURCHASE PLAN PAYABLE 1169023 2075969 X 30669313 0 30669313 363501 363501 31032814 29756940 0 29756940 29089 356284 385373 30142313 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X, LINE 2: MANAGEMENT EVALUATED THE COMPANY'S TAX POSITIONS AND CONCLUDED THAT THE COMPANY HAD TAKEN NO UNCERTAIN TAX POSITIONS THAT REQUIRE ADJUSTMENT TO THE FINANCIAL STATEMENTS. WITH FEW EXCEPTIONS, THE COMPANY IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS BY THE U.S. FEDERAL TAX AUTHORITIES EXCEPT FOR THE LAST THREE YEARS FILED. PART XI, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT INCOME 248,380. GAIN ON SALE OF INVESTMENTS 115,121. PART XII, LINE 4B - OTHER ADJUSTMENTS: NET AMORTIZATION OF PREMIUMS AND DISCOUNTS 16,284. DONATION TO DELTA DENTAL FOUNDATION 340,000. AUDITED FINANCIALS CONTAIN SEPARATE "FINANCIAL INCOME" COMPONENT. THIS COMPONENT TOTALS $318,128 WHICH CONSISTS OF: $363,501 FROM PART XI AND $45,373 FROM PART XII. X 1 1 X X 0 1 0 0 0 0 0 0 0 KERRY HALL 189000 0 10000 0 3353 0 79264 0 20865 0 302482 0 287025 0 PART I, LINE 1A DELTA DENTAL OF WYOMING HAS ADOPTED A COMPENSATION POLICY PURSUANT TO WHICH IT FOLLOWS THE PROCESS OUTLINED IN TREASURY REGULATION SECTION 53.4958-6 TO ESTABLISH THE REBUTTABLE PRESUMPTION OF REASONABLENESS AS TO THE COMPENSATION OF ITS CEO. THIS PROCESS INCLUDES REVIEW AND APPROVAL OF THE COMPENSATION ARRANGEMENT BY A COMPENSATION COMMITTEE COMPOSED ENTIRELY OF PERSONS WITH NO CONFLICT OF INTEREST (AS DEFINED IN REGULATIONS SECTION 53-4958-6(C)(1)(III)), RELIANCE ON COMPARABILITY DATA COMPILED BY AN INDEPENDENT COMPENSATION CONSULTANT AND CONTEMPORANEOUS DOCUMENTATION AND RECORDKEEPING WITH RESPECT TO DELIBERATIONS AND DECISIONS REGARDING THE COMPENSATION ARRANGEMENT. THIS PROCESS IS UNDERTAKEN ANNUALLY WITH RESPECT TO THE CEO AND ALL OTHER DISQUALIFIED PERSONS. IT WAS CONDUCTED ON SEPTEMBER 29, 2012. DELTA DENTAL PAID COUNTRY CLUB DUES FOR KERRY HALL. THIS IS INCLUDED AS PART OF EMPLOYMENT CONTRACT AND WAS INCLUDED IN W-2 WAGES. PART I, LINE 4B KERRY HALL PARTICIPATED IN A SUPPLEMENTAL NONQUALIFIED RETIREMENT PLAN ACCRUING $62,511 IN 2012. DR. EARL KINCHELOE PARTICIPATED IN A SUPPLEMENT NONQUALIFIED RETIREMENT PLAN BUT RECEIVED $0 IN 2012. DR ED CLARK BOARD MEMBER 289942 DENTIST WHO PARTICIPATES IN THE ORGANIZATION'S PROVIDER NETWORK AND RECEIVES REIMBURSEMENT FOR PATIENT CLAIMS FROM THE ORGANIZATION. 0 DR BYRON KILLPACK BOARD MEMBER 322738 DENTIST WHO PARTICIPATES IN THE ORGANIZATION'S PROVIDER NETWORK AND RECEIVES REIMBURSEMENT FOR PATIENT CLAIMS FROM THE ORGANIZATION. 0 DR ROY PAULSON BOARD MEMBER 233109 DENTIST WHO PARTICIPATES IN THE ORGANIZATION'S PROVIDER NETWORK AND RECEIVES REIMBURSEMENT FOR PATIENT CLAIMS FROM THE ORGANIZATION. 0 0 KERRY HALL CEO 11854 ELECTRICAL SYSTEM IN NEW OFFICE CONTRACTED WITH MCKEE HALL ELECTRICAL SYSTEMS WHICH IS CO-OWNED BY THE CEO'S BROTHER. 0 FORM 990, PART VI, SECTION A, LINE 6 MEMBERS ARE COMPRISED OF DENTISTS WHO HAVE CONTRACTS WITH DELTA DENTAL OF WYOMING. FORM 990, PART VI, SECTION A, LINE 7A STATE IS DIVIDED INTO SIX REGIONS WHERE DENTISTS ELECT PARTICIPATING MEMBERS TO THE GOVERNING BODY. SEVEN AT LARGE DIRECTORS (TWO MEMBERS AND FIVE AT LARGE INDIVIDUALS) ARE ALSO ELECTED BY THE MEMBERSHIP. FORM 990, PART VI, SECTION A, LINE 7B AMENDMENTS TO THE ORGANIZATION'S ARTICLES OF INCORPORATION AND BYLAWS MAY BE INITIATED BY THE BOARD OF DIRECTORS BUT REQUIRE APPROVAL OF THE MEMBERS TO BE EFFECTIVE. FORM 990, PART VI, SECTION B, LINE 11 THE ORGANIZATION FOLLOWS A POLICY THAT IS DESIGNED TO ENSURE APPROPRIATE OVERSIGHT AND REVIEW OF THE FORM 990. AN INTERNAL WORKING GROUP INCLUDING THE ORGANIZATION'S CEO, VICE PRESIDENT OF FINANCE, OUTSIDE TAX PREPARER, LEGAL COUNSEL AND OTHERS HELP COMPILE AN INITIAL DRAFT OF FORM 990.ONCE A COMPLETE DRAFT IS DEVELOPED AND REVIEWED BY THE WORKING GROUP, THE DRAFT (WITH ALL ATTACHMENTS) IS SUBMITTED TO THE ORGANIZATION'S BOARD OF DIRECTORS FOR REVIEW AND QUESTIONS. THE BOARD COMPLETED ITS REVIEW AT THE SEPTEMBER 2012 BOARD MEETING, PRIOR TO THE FILING OF FORM 990. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION'S WRITTEN CONFLICT OF INTEREST POLICY COVERS ANY DIRECTOR OR OFFICER. IT REQUIRES DISCLOSURE OF ALL MATERIAL FACTS REGARDING ANY ACTUAL OR POTENTIAL CONFLICTS OF INTEREST ON AN ONGOING BASIS. THE BOARD DETERMINES, BY A MAJORITY OF ITS DISINTERESTED BOARD MEMBERS, WHETHER A CONFLICT OF INTEREST EXISTS. THE BOARD DETERMINES, BY A MAJORITY OF ITS DISINTERESTED PARTIES, WHETHER THE ORGANIZATION CAN OBTAIN A MORE ADVANTAGEOUS TRANSACTION UNDER THE CIRCUMSTANCES THAT WOULD NOT GIVE RISE TO A CONFLICT AND, IF NOT, WHETHER IT IS IN THE ORGANIZATION'S BEST INTERESTS TO GO FORWARD WITH THE TRANSACTION. EACH PERSON SUBJECT TO THE ORGANIZATION'S CONFLICT OF INTEREST POLICY IS REQUIRED TO COMPLETE AN ANNUAL CONFLICT OF INTEREST DISCLOSURE FORM AND HAS A CONTINUING DUTY TO UPDATE SUCH STATEMENT. CONFLICT OF INTEREST DISCLOSURE FORMS ARE REVIEWED ANNUALLY. FORM 990, PART VI, SECTION B, LINE 15A DELTA DENTAL OF WYOMING HAS ADOPTED A COMPENSATION POLICY PURSUANT TO WHICH IT FOLLOWS THE PROCESS OUTLINED IN TREASURY REGULATION SECTION 53.4958-6 TO ESTABLISH THE REBUTTABLE PRESUMPTION OF REASONALBENESS AS TO THE COMPENSATION OF ITS CEO. THIS PROCESS INCLUDES REVIEW AND APPROVAL OF THE COMPENSATION ARRANGEMENT BY A COMPENSATION COMMITTEE COMPOSED ENTIRELY OF PERSONS WITH NO CONFLICT OF INTEREST (AS DEFINED IN REGULATIONS SECTION 53-4958-6(C)(1)(III)), RELIANCE ON COMPARABILITY DATA COMPILED BY AN INDEPENDENT COMPENSATION CONSULTANT AND CONTEMPORANEOUS DOCUMENTATION AND RECORDKEEPING WITH RESPECT TO DELIBERATIONS AND DECISIONS REGARDING THE COMPENSATION ARRANGEMENT. THIS PROCESS IS UNDERTAKEN ANNUALLY WITH RESPECT TO THE CEO AND ALL OTHER DISQUALIFIED PERSONS. IT WAS CONDUCTED ON SEPTEMBER 29, 2012. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FINANCIAL STATEMENTS ARE PROVIDED ANNUALLY TO ALL PARTICIPATING MEMBERS. CONTACT ADDRESSES FOR OFFICERS, DIRECTORS, ETC FORM 990, PART VII DR. BRUCE HOLWELL - PO BOX 187, BIG HORN, WY 82833. DR. JAMES GILMAN - 209 S. 7TH, WORLAND, WY 82401. DR. ROBERT TYRRELL - 1702 ANTELOPE, KEMMERER, WY 83101. BRUCE HINCHEY - 1600 ELKHORN VALLEY DRIVE, CASPER, WY 82609. DR. SCOTT HOUFEK - 16 WEST 3RD, BIG PINEY, WY 83113. DR. BYRON KILLPACK - PO BOX 1150, LARAMIE, WY 82070. ROXANNE OSTLUND - 5920 YELLOWSTONE ROAD, CHEYENNE, WY 82009. BOB PALMER - 5302 TARRY ST., GILLETTE, WY 82718. DR. ROY PAULSON - 102 N. KENWOOD, CASPER, WY 82601. DR. BILL GERN - 1000 E. UNIVERSITY, DEPT 3355, LARAMIE, WY 82071. ROD CHISHOLM - 1051 BONITA DR., LARAMIE, WY 82072. RAY BISHOP - P.O. BOX 485, MOOSE, WY 83012. DR. ED CLARK - 5211 YELLOWSTONE ROAD, CHEYENNE, WY 82009. JEFF MARSH - 120 WEST 22ND AVE., TORRINGTON, WY 82240. PART XI, LINE 2C: DELTA DENTAL HAS A COMMITTEE THAT OVERSEES THE AUDIT