WV - OH SUPPLEMENTAL HEALTH PLAN: Form 990, tax year 2012

View the entire original 990 at ProPublica ↗

Organization
WV - OH SUPPLEMENTAL HEALTH PLAN (EIN 30-0002072)
Tax period
2012-01-01 to 2012-12-31
Filed
2013-11-14
IRS object ID
201343189349301369
Schema version
2012v2.1
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Timestamp2013-11-14T08:47:08-06:00Timestamp
Tax Period End Date2012-12-31TaxPeriodEndDate

Preparer Firm PreparerFirm

FieldValueIRS element (for citing)
EIN550526247EIN

Preparer Firm Business Name PreparerFirmBusinessName

FieldValueIRS element (for citing)
Business Name Line1BODKIN WILSON & KOZICKI PLLCBusinessNameLine1

Preparer Firm US Address PreparerFirmUSAddress

FieldValueIRS element (for citing)
Address Line132 TWENTIETH STREET SUITE 300AddressLine1
CityWHEELINGCity
StateWVState
ZIP Code26003ZIPCode
FieldValueIRS element (for citing)
Return Type990ReturnType
Tax Period Begin Date2012-01-01TaxPeriodBeginDate

Filer Filer

FieldValueIRS element (for citing)
EIN300002072EIN

Name Name

FieldValueIRS element (for citing)
Business Name Line1WV-OH SUPPLEMENTAL HEALTH PLANBusinessNameLine1
FieldValueIRS element (for citing)
Name ControlWV-ONameControl
Phone3045250331Phone

US Address USAddress

FieldValueIRS element (for citing)
Address Line13150 US ROUTE 60AddressLine1
CityONACity
StateWVState
ZIP Code25545ZIPCode

Officer Officer

FieldValueIRS element (for citing)
NameJOHN CLARKEName
TitleBOARD CHAIRMANTitle
Phone3045250331Phone
Date Signed2013-11-13DateSigned

Preparer Preparer

FieldValueIRS element (for citing)
NameNANCY J GWYNN CPAName
PTINP01447261PTIN
Phone3042322280Phone
Date Prepared2013-11-13DatePrepared
FieldValueIRS element (for citing)
Tax Year2012TaxYear
Build TS2016-02-25 16:41:14ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Address ChangeXAddressChange
Name Of Principal Officer PersonJOHN CLARKENameOfPrincipalOfficerPerson

Address Principal Officer US AddressPrincipalOfficerUS

FieldValueIRS element (for citing)
Address Line182 BURKHAM COURTAddressLine1
CityWHEELINGCity
StateWVState
ZIP Code26003ZIPCode
FieldValueIRS element (for citing)
Gross Receipts910801GrossReceipts
Group Return For Affiliates0GroupReturnForAffiliates
Organization501cXOrganization501c
Web SiteNAWebSite
Type Of Organization TrustXTypeOfOrganizationTrust
Year Formation2001YearFormation
State Legal DomicileWVStateLegalDomicile
Activity Or Mission DescriptionPROVIDING SUPPLEMENTAL HEALTH PREMIUMS AND WEEKLY DISABILITY BENEFITS TO ELIGIBLE MEMBERSActivityOrMissionDescription
Nbr Voting Members Governing Body12NbrVotingMembersGoverningBody
Nbr Independent Voting Members12NbrIndependentVotingMembers
Total Nbr Employees0TotalNbrEmployees
Total Nbr Volunteers12TotalNbrVolunteers
Total Gross UBI0TotalGrossUBI
Net Unrelated Business Txbl Income0NetUnrelatedBusinessTxblIncome
Contributions Grants Prior Year0ContributionsGrantsPriorYear
Contributions Grants Current Year0ContributionsGrantsCurrentYear
Program Service Revenue Prior Year762862ProgramServiceRevenuePriorYear
Program Service Revenue CY712530ProgramServiceRevenueCY
Investment Income Prior Year147515InvestmentIncomePriorYear
Investment Income Current Year198271InvestmentIncomeCurrentYear
Other Revenue Prior Year0OtherRevenuePriorYear
Other Revenue Current Year0OtherRevenueCurrentYear
Total Revenue Prior Year910377TotalRevenuePriorYear
Total Revenue Current Year910801TotalRevenueCurrentYear
Grants And Similar Amnts Prior Year0GrantsAndSimilarAmntsPriorYear
Grants And Similar Amnts CY0GrantsAndSimilarAmntsCY
Benefits Paid To Members Prior Year565563BenefitsPaidToMembersPriorYear
Benefits Paid To Members CY630636BenefitsPaidToMembersCY
Salaries Etc Prior Year0SalariesEtcPriorYear
Salaries Etc Current Year0SalariesEtcCurrentYear
Total Prof Fundrsng Exp Prior Year0TotalProfFundrsngExpPriorYear
Total Prof Fundrsng Exp CY0TotalProfFundrsngExpCY
Total Fundrsng Exp Current Year0TotalFundrsngExpCurrentYear
Other Expense Prior Year43146OtherExpensePriorYear
Other Expenses Current Year72488OtherExpensesCurrentYear
Total Expenses Prior Year608709TotalExpensesPriorYear
Total Expenses Current Year703124TotalExpensesCurrentYear
Revenues Less Expenses Prior Year301668RevenuesLessExpensesPriorYear
Revenues Less Expenses CY207677RevenuesLessExpensesCY
Total Assets BOY3569234TotalAssetsBOY
Total Assets EOY3993970TotalAssetsEOY
Total Liabilities BOY0TotalLiabilitiesBOY
Total Liabilities EOY114147TotalLiabilitiesEOY
Net Assets Or Fund Balances BOY3569234NetAssetsOrFundBalancesBOY
Net Assets Or Fund Balances EOY3879823NetAssetsOrFundBalancesEOY
Mission DescriptionTO PROVIDE SUPPLEMENTAL HEALTH PREMIUMS & WEEKLY DISABILITY BENEFITS TO ELIGIBLE MEMBERS OF PARTICIPATING INTERNATIONAL BROTHERHOOD OF ELECTRICAL WORKERS (IBEW) UNIONSMissionDescription
Significant New Program Services0SignificantNewProgramServices
Significant Change0SignificantChange
Expense535545Expense
DescriptionTHE PROVISION OF SUPPLEMENTAL HEALTH INSURANCE PREMIUMS FOR ELIGIBLE MEMBERS OF THE PARTICIPATING LOCAL IBEW UNIONSDescription

Activity2 Activity2

FieldValueIRS element (for citing)
Expense95091Expense
DescriptionTHE PROVISION OF SUPPLEMENTAL DISABILITY BENEFITS TO ELIGIBLE MEMBERS OF PARTICIPATING IBEW LOCAL UNIONSDescription
FieldValueIRS element (for citing)
Total Program Service Expense630636TotalProgramServiceExpense
Described In501 C30DescribedIn501C3
Schedule B Required0ScheduleBRequired
Political Activities0PoliticalActivities
Subject To Proxy Tax0SubjectToProxyTax
Donor Advised Funds0DonorAdvisedFunds
Conservation Easements0ConservationEasements
Collections Of Art0CollectionsOfArt
Credit Counseling0CreditCounseling
Term Or Permanent Endowments0TermOrPermanentEndowments
Report Land Bldg Equip0ReportLandBldgEquip
Report Invest Oth Securities0ReportInvestOthSecurities
Report Prog Rel Invest0ReportProgRelInvest
Report Other Assets0ReportOtherAssets
Report Other Liabilities0ReportOtherLiabilities
Report Fin48 Footnote0ReportFin48Footnote
Independent Audit Financial Stmt1IndependentAuditFinancialStmt
Consolidated Audit Financial Stmt0ConsolidatedAuditFinancialStmt
School0School
Foreign Office0ForeignOffice
Foreign Activities0ForeignActivities
More Than5000 K To Organizations0MoreThan5000KToOrganizations
More Than5000 K To Individuals0MoreThan5000KToIndividuals
Professional Fundraising0ProfessionalFundraising
Fundraising Activities0FundraisingActivities
Gaming0Gaming
Hospital0Hospital
Grants To Organizations0GrantsToOrganizations
Grants To Individuals0GrantsToIndividuals
Schedule J Required0ScheduleJRequired
Tax Exempt Bonds0TaxExemptBonds
Loan To Officer Or DQP0LoanToOfficerOrDQP
Grant To Related Person0GrantToRelatedPerson
Bsnss Rltnshp With Organization0BsnssRltnshpWithOrganization
Bsnss Rltnshp Thru Family Member0BsnssRltnshpThruFamilyMember
Officer Entity With Bsnss Rltnshp0OfficerEntityWithBsnssRltnshp
Deductible Non Cash Contributions0DeductibleNonCashContributions
Deductible Contributions Of Art0DeductibleContributionsOfArt
Terminated0Terminated
Partial Liquidation0PartialLiquidation
Disregarded Entity0DisregardedEntity
Related Entity0RelatedEntity
Related Org Controlled Entity0RelatedOrgControlledEntity
Activities Conducted Partnership0ActivitiesConductedPartnership
Schedule O Required1ScheduleORequired
Number Forms Transmitted With10966NumberFormsTransmittedWith1096
Number W2 G Included0NumberW2GIncluded
Number Of Employees0NumberOfEmployees
Unrelated Business Income0UnrelatedBusinessIncome
Foreign Financial Account0ForeignFinancialAccount
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTrans
Taxable Party Notification0TaxablePartyNotification
Non Deductible Contributions0NonDeductibleContributions
Quid Pro Quo Contributions0QuidProQuoContributions
Form8282 Property Disposed Of0Form8282PropertyDisposedOf
Indoor Tanning Services0IndoorTanningServices
Info In Schedule O Part VIXInfoInScheduleOPartVI
Nbr Voting Governing Body Members12NbrVotingGoverningBodyMembers
Number Independent Voting Members12NumberIndependentVotingMembers
Family Or Business Relationship0FamilyOrBusinessRelationship
Delegation Of Management Duties0DelegationOfManagementDuties
Changes To Organizing Docs0ChangesToOrganizingDocs
Material Diversion Or Misuse0MaterialDiversionOrMisuse
Members Or Stockholders0MembersOrStockholders
Election Of Board Members0ElectionOfBoardMembers
Decisions Subject To Approval0DecisionsSubjectToApproval
Minutes Of Governing Body1MinutesOfGoverningBody
Minutes Of Committees1MinutesOfCommittees
Officer Mailing Address0OfficerMailingAddress
Local Chapters0LocalChapters
Form990 Provided To Governing Body0Form990ProvidedToGoverningBody
Conflict Of Interest Policy0ConflictOfInterestPolicy
Whistleblower Policy0WhistleblowerPolicy
Document Retention Policy0DocumentRetentionPolicy
Compensation Process CEO0CompensationProcessCEO
Compensation Process Other0CompensationProcessOther
Investment In Joint Venture0InvestmentInJointVenture
States Where Copy Of Return Is FiledWVStatesWhereCopyOfReturnIsFiled
Upon RequestXUponRequest

The Books Are In Care Of TheBooksAreInCareOf

Name Business NameBusiness

FieldValueIRS element (for citing)
Business Name Line1AMERICAN BENEFIT CORPORATIONBusinessNameLine1
FieldValueIRS element (for citing)
Telephone Number3045250331TelephoneNumber

Address US AddressUS

FieldValueIRS element (for citing)
Address Line13150 US ROUTE 60AddressLine1
CityONACity
StateWVState
ZIP Code25545ZIPCode
FieldValueIRS element (for citing)
No Listed Persons CompensatedXNoListedPersonsCompensated

Form990 Part VII Section A Form990PartVIISectionA (12 entries)

TitleTitleAverage Hours Per WeekAverageHoursPerWeekIndividual Trustee Or DirectorIndividualTrusteeOrDirectorReportable Comp From OrganizationReportableCompFromOrganizationReportable Comp From Related OrgsReportableCompFromRelatedOrgsOther CompensationOtherCompensationOfficerOfficer
TROY FERRELL
TRUSTEE1.00X000
SHANE FERGUSON
TRUSTEE1.00X000
DANA JOE SAMPLES
TRUSTEE1.00X000
LYNFORD LOVELL
TRUSTEE1.00X000
WILLIAM HAMILTON
TRUSTEE1.00X000
ROBERT A KUBOVICZ
TRUSTEE1.00X000
STEVEN ALLRED
TRUSTEE1.00X000
JEFF WILLIAMSON
TRUSTEE1.00X000
JAMES BANE
TRUSTEE1.00X000
BRIAN DAMANT
TRUSTEE1.00X000
JOHN CLARKE
BOARD CHARIMAN1.00000X
DAVID K ROGERS
SECRETARY / TREASURER1.00000X
FieldValueIRS element (for citing)
Total Reportable Comp From Org0TotalReportableCompFromOrg
Total Reportable Comp Frm Rltd Orgs0TotalReportableCompFrmRltdOrgs
Total Other Compensation0TotalOtherCompensation
Number Individuals GT100 K0NumberIndividualsGT100K
Formers Listed0FormersListed
Total Comp GT150 K0TotalCompGT150K
Compensation From Other Sources0CompensationFromOtherSources
Number Of Contractors GT100 K0NumberOfContractorsGT100K

Program Service Revenue ProgramServiceRevenue

FieldValueIRS element (for citing)
DescriptionEMPLOYER CONTRIBUTIONSDescription
Business Code525100BusinessCode
Total Revenue Column712530TotalRevenueColumn
Related Or Exempt Function Income712530RelatedOrExemptFunctionIncome
FieldValueIRS element (for citing)
Total Program Service Revenue712530TotalProgramServiceRevenue

Investment Income InvestmentIncome

FieldValueIRS element (for citing)
Total Revenue Column198271TotalRevenueColumn
Exclusion$198,271ExclusionAmount

Total Revenue TotalRevenue

FieldValueIRS element (for citing)
Total Revenue Column910801TotalRevenueColumn
Related Or Exempt Function Income712530RelatedOrExemptFunctionIncome
Unrelated Business Revenue0UnrelatedBusinessRevenue
Exclusion$198,271ExclusionAmount

Benefits To Members BenefitsToMembers

FieldValueIRS element (for citing)
Total630636Total

Fees For Services Management FeesForServicesManagement

FieldValueIRS element (for citing)
Total18000Total

Fees For Services Legal FeesForServicesLegal

FieldValueIRS element (for citing)
Total1935Total

Fees For Services Accounting FeesForServicesAccounting

FieldValueIRS element (for citing)
Total20000Total

Fees For Services Invst Mgmnt Fees FeesForServicesInvstMgmntFees

FieldValueIRS element (for citing)
Total14451Total

Fees For Services Other FeesForServicesOther

FieldValueIRS element (for citing)
Total15000Total

Office Expenses OfficeExpenses

FieldValueIRS element (for citing)
Total1162Total

Insurance Insurance

FieldValueIRS element (for citing)
Total1940Total

Total Functional Expenses TotalFunctionalExpenses

FieldValueIRS element (for citing)
Total703124Total

Savings And Temp Cash Investments SavingsAndTempCashInvestments

FieldValueIRS element (for citing)
BOY127819BOY
EOY244771EOY

Accounts Receivable AccountsReceivable

FieldValueIRS element (for citing)
BOY84646BOY
EOY70627EOY

Prepaid Expenses Deferred Charges PrepaidExpensesDeferredCharges

FieldValueIRS element (for citing)
EOY44245EOY

Investments Pub Traded Securities InvestmentsPubTradedSecurities

FieldValueIRS element (for citing)
BOY3308121BOY
EOY3612034EOY

Investments Other Securities InvestmentsOtherSecurities

FieldValueIRS element (for citing)
EOY12959EOY

Other Assets Total OtherAssetsTotal

FieldValueIRS element (for citing)
BOY48648BOY
EOY9334EOY

Total Assets TotalAssets

FieldValueIRS element (for citing)
BOY3569234BOY
EOY3993970EOY

Accounts Payable Accrued Expenses AccountsPayableAccruedExpenses

FieldValueIRS element (for citing)
EOY114147EOY

Total Liabilities TotalLiabilities

FieldValueIRS element (for citing)
BOY0BOY
EOY114147EOY
FieldValueIRS element (for citing)
Do Not Follow SFAS117XDoNotFollowSFAS117

Cap Stck Trst Prin Current Funds CapStckTrstPrinCurrentFunds

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Paid In Cap Srpls Land Bldg Eqp Fund PaidInCapSrplsLandBldgEqpFund

FieldValueIRS element (for citing)
BOY0BOY
EOY0EOY

Retained Earnings Endowment Etc RetainedEarningsEndowmentEtc

FieldValueIRS element (for citing)
BOY3569234BOY
EOY3879823EOY

Total Net Assets Fund Balances TotalNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY3569234BOY
EOY3879823EOY

Total Liab Net Assets Fund Balances TotalLiabNetAssetsFundBalances

FieldValueIRS element (for citing)
BOY3569234BOY
EOY3993970EOY
FieldValueIRS element (for citing)
Reconcilation Revenue Expenses207677ReconcilationRevenueExpenses
Reconciliation Unrealized Invest102912ReconciliationUnrealizedInvest
Reconcilation Other Changes0ReconcilationOtherChanges
Info In Schedule O Part XIIXInfoInScheduleOPartXII
Method Of Accounting AccrualXMethodOfAccountingAccrual
Accountant Compile Or Review0AccountantCompileOrReview
FS Audited1FSAudited

FS Audited Basis FSAuditedBasis

FieldValueIRS element (for citing)
Financial Statement SeparateXFinancialStatementSeparate
FieldValueIRS element (for citing)
Audit Committee1AuditCommittee
Federal Grant Audit Required0FederalGrantAuditRequired

Schedule D IRS990ScheduleD

FieldValueIRS element (for citing)
Total Of Book Value Land Buildings0TotalOfBookValueLandBuildings
Tot Revenue Etc Audited Fincl Stmt1013713TotRevenueEtcAuditedFinclStmt
Net Unrealized Gains Investments102912NetUnrealizedGainsInvestments
Revenue Not Rptd F990102912RevenueNotRptdF990
Revenue Subtotal910801RevenueSubtotal
Revenue Not Rptd On Fin Stmt0RevenueNotRptdOnFinStmt
Total Revenue Per Form990910801TotalRevenuePerForm990
Tot Expenses Etc Audited Fincl Stmt703124TotExpensesEtcAuditedFinclStmt
Expenses Not Rptd F9900ExpensesNotRptdF990
Expenses Subtotal703124ExpensesSubtotal
Expenses Not Rptd On Fin Stmt0ExpensesNotRptdOnFinStmt
Total Expenses Per Form990703124TotalExpensesPerForm990

Schedule O IRS990ScheduleO

General Explanation GeneralExplanation (3 entries)

Return ReferenceReturnReferenceExplanationExplanation
FORM 990, PART VI, SECTION B, LINE 11THE ORGANIZATION'S FORM 990 IS PREPARED ANNUALLY BY AN INDEPENDENT ACCOUNTING FIRM. THE FIRM SENDS A DRAFT TO THE ONE OR MORE MEMBERS OF THE GOVERNING BODY TO BE DISTRIBUTED TO THE REMAINING MEMBERS BEFORE THE FORM IS SIGNED BY AN AUTHORIZED MEMBER AND FILED WITH THE APPROPRIATE TAX AUTHORITIES.
FORM 990, PART VI, SECTION C, LINE 19THIS 990 IS ALWAYS PUBLICALLY AVAILABLE THROUGH GUIDESTAR.COM; HOWEVER, THE PLAN'S GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND AUDITED FINANCIAL STATEMENTS ARE ONLY AVAILABLE UPON REQUEST TO INTERESTED PARTIES.
PART XII; QUESTION 2CTHE ORGANIZATIONS GOVERNANCE COMMITTEE SELECTS THE AUDITOR AND REVIEWS THE AUDITORS REPORTS EACH YEAR.

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