2012-11-15T13:34:19-06:00 2011-12-31 381357951 PLANTE & MORAN PLLC 1111 MICHIGAN AVE EAST LANSING MI 48823 990 2011-01-01 610659432 DELTA DENTAL OF KENTUCKY INC DELT 5027365000 10100 LINN STATION ROAD NO 700 LOUISVILLE KY 40223 RUSSELL W SKAGGS 5027365000 2012-11-15 1 SUSAN MIENCIER CPA P00842339 5173326200 2011 2016-02-24 21:20:13Z CLIFFORD T MAESAKA JR 10100 LINN STATION ROAD NO 700 LOUISVILLE KY 40223 157300582 0 X WWW.DELTADENTALKY.COM X 1966 KY DELTA DENTAL PLAN OF KENTUCKY'S MISSION HAS ALWAYS BEEN TO BE THE LEADER IN OUR MARKETS, TO DELIVER UNMATCHED QUALITY AND VALUE IN OUR PROGRAMS AND SERVICES, AND TO VIGOROUSLY PROMOTE THE IMPORTANCE OF ORAL HEALTH AS AN ESSENTIAL PART OF OVERALL HEALTH. ITS OVERARCHING MISSION IS TO BE THE DENTAL BENEFITS COMPANY OF CHOICE IN THE MARKETS WE SERVE. 13 12 86 0 0 0 0 0 135204433 150374666 290638 710008 286405 -189611 135781476 150895063 100000 41850 116794128 129104585 6348079 6920321 0 0 0 9381121 9796897 132623328 145863653 3158148 5031410 63574460 69833049 16449340 17111794 47125120 52721255 X DELTA DENTAL PLAN OF KENTUCKY'S MISSION HAS ALWAYS BEEN TO BE THE LEADER IN OUR MARKETS, TO DELIVER UNMATCHED QUALITY AND VALUE IN OUR PROGRAMS AND SERVICES, AND TO VIGOROUSLY PROMOTE THE IMPORTANCE OF ORAL HEALTH AS AN ESSENTIAL PART OF OVERALL HEALTH. ITS OVERARCHING MISSION IS TO BE THE DENTAL BENEFITS COMPANY OF CHOICE IN THE MARKETS WE SERVE. 0 0 143439685 41850 150374666 THE ORGANIZATION PROVIDES ACCESS TO ORAL HEALTH CARE PROVIDERS THROUGH DENTAL BENEFIT PROGRAMS AS A MEMBER OF THE DELTA DENTAL PLANS ASSOCIATION. SERVICES BENEFITED APPROXIMATELY 615,000 INDIVIDUALS. 143439685 0 0 0 0 0 0 0 0 0 1 1 0 1 1 1 0 1 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 17589 0 1 86 1 0 0 0 0 0 0 X 13 12 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X X RUSSELL W SKAGGS VP - FINANCE 5027365000 10100 LINN STATION ROAD STE 700 LOUISVILLE KY 40223 X CARRIE B BROWN DMD 2.00 X 16650 0 0 MICHAEL CHILDERS DMD 2.00 X 19600 0 0 MARY M CORBETT 2.00 X 16050 0 0 OLIVIA F KIRTLEY 2.00 X 650 0 16500 MICHAEL B MOUNTJOY 2.00 X 3000 0 16500 JOHN L G RICHARDS 2.00 X 13500 0 0 C RICHARD SEITZ 2.00 X 15900 0 0 BRUCE R SMITH 2.00 X 16650 0 0 JEFFREY C SMITH 2.00 X 32000 0 0 J JUDE THOMPSON 2.00 X 16650 0 0 JOHN N WILLIAMS JR DMD 2.00 X X 22500 0 0 CLIFFORD T MAESAKA JR 35.00 X X 504345 0 29578 J DAVID SMITH 2.00 X 16650 0 0 STEPHEN C DAY 40.00 X 242142 0 24890 JOHN L WEEKS III 40.00 X 261695 0 25787 ANGELA J NENNI 40.00 X 201542 0 16980 TAMARA L YORK-DAY 40.00 X 245014 0 19484 GORAN JURKOVIC CPA 2.00 X 0 513177 261799 RUSSELL W SKAGGS 40.00 X 161574 0 22801 RONALD E STORY 40.00 X 130080 0 15387 LINA K STIRSMAN 40.00 X 124220 0 11922 BRIAN E KRAINER 40.00 X 174905 0 15188 JAMES C FINN 40.00 X 178837 0 16687 CURTIS R LADIG 40.00 X 172157 0 0 2586311 513177 493503 10 1 1 0 ANTHEM BCBS KY GROUP 11675 CENTURY DRIVE ATLANTA GA 30009 HEALTH INSURANCE COVERAGE 585678 VINTAGE PRINTING 967 S 11TH ST LOUISVILLE KY 40210 PRINTING & POSTAGE 486610 VISION SERVICE PLAN 1 EMBARCADERO CENTER 1540 SAN FRANCISCO CA 94160 VISION COVERAGE 219922 PITNEY BOWES PURCHASE POWER 800 VINIAL STREET PITTSBURGH PA 15212 POSTAGE MAILINGS 209400 DELTA DENTAL OF VIRGINIA 4860 COX ROAD SUITE 130 GLEN ALLEN VA 23060 ANNUAL SYSTEM MAINTENANCE 178445 7 SUBSCRIBER REVENUE 524114 150356666 150356666 SUBSIDIARY MANAGEMENT 900099 18000 18000 150374666 672580 672580 281612 471223 -189611 -189611 -189611 5971724 5934296 37428 37428 37428 150895063 150374666 0 520397 41850 41850 129104585 129104585 1631864 349137 1282727 4276671 4276671 14101 14101 641226 641226 356459 273761 82698 168813 168813 87923 87923 165798 165798 281179 253061 28118 358651 233123 125528 597492 597492 821734 714909 106825 316273 158137 158136 18923 11354 7569 53 53 117662 105896 11766 190684 190684 BROKER COMMISSIONS 5240248 5240248 POSTAGE & SHIPPING 738308 730925 7383 PRINTING & PUBLICATIONS 234353 234353 PROCESSING FEES 221080 221080 237723 237723 145863653 143439685 2423968 0 6335473 11845904 370969 329382 7412860 7290344 270510 97900 13788922 4216996 9928055 9571926 17656842 18204953 17076691 17318615 4523060 5174025 63574460 69833049 2867825 3135062 2537767 2662755 11043748 11313977 16449340 17111794 X 47125120 52721255 47125120 52721255 63574460 69833049 X 5031410 564725 X X 0 1 1 X 0 830000 830000 9779985 1634689 8145296 88682 51015 37667 1734898 1176013 558885 1355357 1355279 78 9571926 11011608 F INVESTMENT - DENTAL CHOICE, INC. 6307007 F 17318615 ACCRUED INVESTMENT INCOME 249146 457(B) PLAN 318549 INVESTMENT - RHC 3006330 SURPLUS NOTE RECEIVABLE 1600000 5174025 CLAIMS CHECKS OUTSTANDING 6202613 ESTIMATED CLAIMS LIABILITY 5111364 11313977 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: AS OF DECEMBER 31, 2011 AND 2010, THE COMPANY'S UNRECOGNIZED TAX BENEFITS WERE NOT SIGNIFICANT. THERE WERE NO SIGNIFICANT PENALTIES OR INTEREST RECOGNIZED DURING THE YEAR OR ACCRUED AT YEAR END. 0 X X 1 1 X X X X 1 1 0 0 0 0 0 0 0 CLIFFORD T MAESAKA JR 246400 0 156729 0 101216 0 14249 0 15329 0 533923 0 0 0 STEPHEN C DAY 160265 0 80476 0 1401 0 9303 0 15587 0 267032 0 0 0 JOHN L WEEKS III 171755 0 87594 0 2346 0 10019 0 15768 0 287482 0 0 0 ANGELA J NENNI 134105 0 65881 0 1556 0 7740 0 9240 0 218522 0 0 0 TAMARA L YORK-DAY 155698 0 88881 0 435 0 8985 0 10499 0 264498 0 0 0 GORAN JURKOVIC CPA 0 257272 0 245516 0 10389 0 236746 0 25053 0 774976 0 0 RUSSELL W SKAGGS 127364 0 33670 0 540 0 7360 0 15441 0 184375 0 0 0 BRIAN E KRAINER 89031 0 85737 0 137 0 10065 0 5123 0 190093 0 0 0 JAMES C FINN 88248 0 89669 0 920 0 10291 0 6396 0 195524 0 0 0 CURTIS R LADIG 0 0 0 0 172157 0 0 0 0 0 172157 0 0 0 PART I, LINE 1A FOR THE ANNUAL RHSC CONFERENCE THE BOARD MEMBERS ARE ALLOWED TO HAVE COMPANION TRAVEL WITH THEM. THIS IS TAXABLE TO THE BOARD MEMBER. PART I, LINES 4A-B PART I, LINES 4A-B: CURTIS R. LADIG - SEVERANCE PAY - $172,157 IN 2011, DELTA DENTAL OF KENTUCKY PAID OUT CURTIS LADIG'S REMAINING CONTRACT AND BENEFITS. DELTA DENTAL PLAN OF KENTUCKY, HAS BOTH A 457(B) PLAN AS WELL AS A SERP, A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN. ONLY ONE POSITION, THE CEO, IS ELIGIBLE FOR THE SERP. ADDITIONALLY, ALL OTHER VPS AND BOARD MEMBERS ARE ELIGIBLE FOR THE 457(B) PLAN. FORM 990, PART VI, SECTION A, LINE 6 EFFECTIVE JULY 1, 2009 RENAISSANCE HEALTH SERVICE CORPORATION BECAME THE SOLE CORPORATE MEMBER OF DELTA DENTAL OF KENTUCKY. FORM 990, PART VI, SECTION A, LINE 7A RHSC IS THE SOLE VOTING MEMBER OF DDKY. HOWEVER, UNDER THE TERMS OF THE AFFILIATION AGREEMENT THE PARTIES AGREED THAT THE DELTA DENTAL OF KENTUCKY (DDKY) BOARD SELECTS DIRECTOR CANDIDATES AND SUBMITS THEM TO RENAISSANCE HEALTH SERVICE CORP (RHSC). RHSC THEN APPROVES THE CANDIDATES. RHSC CAN REJECT PROPOSED CANDIDATES FOR "JUST CAUSE" AS DEFINED IN THE AGREEMENT. OTHERWISE, RHSC MUST APPROVE ALL THE CANDIDATES PROPOSED BY THE DDKY BOARD. RHSC HAS THE RIGHT TO ELECT A NUMBER OF DIRECTORS TO THE DDKY BOARD PROPORTIONAL TO THE NUMBER OF DIRECTORS THAT DDKY MAY NOMINATE TO THE RHSC BOARD. CURRENTLY, RHSC APPOINTS TWO MEMBERS OF THE 13 MEMBER DDKY BOARD. FORM 990, PART VI, SECTION A, LINE 7B THE RIGHTS OF THE DDKY BOARD ARE TO APPROVE THE ANNUAL BUDGETS FOR OPERATIONS, ELECT OFFICERS OF THE DDKY BOARD OF DIRECTORS, APPROVE THE TRANSFER OF ANY OF ITS ASSETS, APPROVE THE INCURRENCE OR GUARANTY OF DEBT AND APPROVE THE MANAGEMENT OF ITS INVESTMENTS. RHSC MUST APPROVE ANY TRANSFER OF ASSETS, INVESTMENTS, LOANS, GUARANTIES OR EXPENDITURES WHICH EXCEED TEN PERCENT OF DDKY'S NET ASSETS. RHSC MUST APPROVE THE FOLLOWING CHANGES TO THE DDKY BYLAWS: THE IDENTITY, QUALIFICATION OR RIGHTS OF DDKY'S VOTING MEMBER, THE QUALIFICATIONS, CLASSIFICATIONS, TERMS OF OFFICE OR PERMISSIBLE NUMBER OF DIRECTORS ON DDKY'S BOARD OR ANY LIMITATION ON THE RIGHTS OR AUTHORITY OF THE DDKY BOARD CONTAINED IN DDKY'S ORGANIZATIONAL DOCUMENTS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS FIRST REVIEWED INTERNALLY BY THE VP-FINANCE, THE IN-HOUSE LEGAL COUNSEL, CEO AND THEN A DRAFT IS PRESENTED TO THE AUDIT AND FINANCE COMMITTEE FOR REVIEW. PRIOR TO FILING, A COPY OF THE FINAL FORM 990 IS DISTRIBUTED TO THE ENTIRE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 12C OFFICERS, DIRECTORS AND KEY EMPLOYEES MUST COMPLETE AND SUBMIT A CONFLICT OF INTEREST DISCLOSURE ANNUALLY. THESE FORMS ARE REVIEWED BY THE CEO, THE CORPORATE COMPLIANCE OFFICER, AND A REPORT IS MADE TO THE AUDIT AND FINANCE COMMITTEE OF THE BOARD OF DIRECTORS. THE AUDIT COMMITTEE REVIEWS ALL POTENTIAL CONFLICTS TO DETERMINE IF THE CONFLICTS REPRESENT MATERIAL FINANCIAL RISK TO THE COMPANY AND TAKES ANY ACTION NECESSARY TO RESOLVE OR MITIGATE THE EFFECT OF THE CONFLICTS. WHEN A CONFLICT EXISTS AMONG THE VOTING BOARD MEMBERS, THAT BOARD MEMBER WILL ABSTAIN FROM VOTING ON THE CONFLICTED ISSUE. ALL EMPLOYEES AND DIRECTORS ARE ADVISED ANNUALLY OF THE REQUIREMENT TO REPORT ANY POTENTIAL CONFLICTS OF INTEREST AS THEY OCCUR. EMPLOYEES AND DIRECTORS MAY ALSO MAKE ANONYMOUS REPORTS OF ANY VIOLATIONS OF CORPORATE POLICIES THROUGH A DEDICATED WHISTLEBLOWER SYSTEM ADMINISTERED BY A THIRD PARTY. FORM 990, PART VI, SECTION B, LINE 15 CEO AND OTHER OFFICERS COMPENSATION ARE REVIEWED BY THE PERSONNEL AND COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS. THE PROCESS IS PERFORMED, AT A MINIMUM, ANNUALLY. COMPENSATION WAS LAST REVIEWED BY DELTA DENTAL OF KENTUCKY'S P&C COMMITEE IN FEBRUARY 2012. THE COMMITTEE IS MADE UP OF INDEPENDENT BOARD MEMBERS. THE COMMITTEE UTILIZES CERTAIN COMPENSATION SURVEYS AND OUTSIDE CONSULTANTS ARE ENGAGED AS NEEDED. COMPENSATION WAS ALSO REVIEWED UNDER DELTA DENTAL PLAN OF MICHIGAN'S HR EXECUTIVE COMPENSATION PROCESS DURING 2010. THE REPORT BASED ON THIS REVIEW WAS THEN ISSUED BY THE CONSULTANTS IN JANUARY OF 2011. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE FILED WITH THE KENTUCKY DEPARTMENT OF INSURANCE AND ARE AVAILABLE FOR INSPECTION BY THE PUBLIC THROUGH THAT AGENCY. ADDITIONALLY, THE COMPANY MAKES ORGANIZATIONAL DOCUMENTS, CONFLICT OF INTEREST POLICIES, AND FINANCIAL STATEMENTS AVAILABLE AT NO COST UPON RECEIPT OF A WRITTEN REQUEST. FORM 990 PART VII SECTION A: HOURS DEVOTED TO RELATED ORGANIZATIONS: GORAN JURKOVIC, CPA- 48 HOURS MICHAEL B. MOUNTJOY-5.5 HOURS C. RICHARD SEITZ- 11 HOURS BRUCE R. SMITH- 15 HOURS CURTIS R. LADIG- 50 HOURS CLIFFORD T. MAESAKA, JR.- 5 HOURS OLIVIA F. KIRTLEY - 5 HOURS CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 268,150. UNREALIZED GAIN/LOSS ON INVESTMENTS IN PRIOR PERIODS 31,101. EQUITY IN SUBSIDIARY 265,474. TOTAL TO FORM 990, PART XI, LINE 5: 564,725. FORM 990, PART XII, LINE 2C: PROCESS IS THE SAME AS THE PRIOR YEAR. FORM 990, PART IV, LINE 12A: THE ORGANIZATION ISSUES INDEPENDENT AUDITED FINANCIAL STATEMENTS ON THE STATUTORY BASIS OF ACCOUNTING. THE ORGANIZATION IS ALSO PART OF A CONSOLIDATED GAAP BASIS FINANCIAL STATEMENT. RENAISSANCE HEALTH SERVICE CORPORATION PO BOX 30416 LANSING MI 489097916 381675667 PROMOTING DENTAL CARE MI 501(C)(4) N/A N/A 0 DELTA DENTAL PLAN OF MICHIGAN INC 4100 OKEMOS ROAD OKEMOS MI 48864 381791480 PROVIDE DENTAL SERVICE PLANS MI 501(C)(4) N/A RENAISSANCE HEALTH SERVICE CORPORATION 1 DELTA DENTAL OF TENNESSEE INC PO BOX 30416 LANSING MI 489097916 620812197 PROVIDE DENTAL SERVICE PLANS TN 501(C)(4) N/A RENAISSANCE HEALTH SERVICE CORPORATION 1 DELTA DENTAL PLAN OF NEW MEXICO INC PO BOX 30416 LANSING MI 489097916 850224562 PROVIDE DENTAL SERVICE PLANS NM 501(C)(4) N/A RENAISSANCE HEALTH SERVICE CORPORATION 1 DELTA DENTAL OF NORTH CAROLINA PO BOX 30416 LANSING MI 489097916 561018068 PROVIDE DENTAL SERVICE PLANS NC 501(C)(4) N/A RENAISSANCE HEALTH SERVICE CORPORATION 1 DELTA DENTAL PLAN OF OHIO INC PO BOX 30416 LANSING MI 489097916 310685339 PROVIDE DENTAL SERVICE PLANS OH 501(C)(4) N/A DELTA DENTAL PLAN OF MICHIGAN INC 1 DELTA DENTAL PLAN OF INDIANA INC PO BOX 30416 LANSING MI 489097916 351545647 PROVIDE DENTAL SERVICE PLANS IN 501(C)(4) N/A DELTA DENTAL PLAN OF MICHIGAN INC 1 DELTA DENTAL FUND PO BOX 30416 LANSING MI 489097916 382337000 SUPPORT DENTAL EDUCATION AND RESEARCH PROGRAMS MI 501(C)(3) 11A TYPE II DELTA DENTAL PLAN OF MICHIGAN INC 1 SUITE 244 PARTNERS LLC 240 VENTURE CIRCLE NASHVILLE TN 37228 203643584 HOLDS THE LEASE TO SUITE 244 AT LP FIELD (TITANS STADIUM) TN FORE HOLDING CORPORATION N/A 0 0 LIQUID CORN LLC 240 VENTURE CIRCLE NASHVILLE TN 37228 203449680 OWNS SUITE 244 TN FORE HOLDING CORPORATION N/A 0 0 PREMIER INSURANCE SERVICES LLC 240 VENTURE CIRCLE NASHVILLE TN 37228 113662057 INSURANCE BROKER TN FORE HOLDING CORPORATION N/A 0 0 DENTAL CHOICE PROPERTIES LLC 10100 LINN STATION RD SUITE 700 LOUISVILLE KY 40223 610659432 HOLDING COMPANY KY DELTA DENTAL OF KENTUCKY INC N/A 0 0 DENTAL CHOICE INC 10100 LINN STATION RD SUITE 700 LOUISVILLE KY 40223 611105118 REAL ESTATE HOLDING COMPANY KY N/A C 85846 6108783 1.00000 DENTAL CHOICE AGENCY INC 10100 LINN STATION RD SUITE 700 LOUISVILLE KY 40223 611336003 PRIMARY GENERAL AGENCY FOR DDKY & DENTAL CHOICE KY N/A C 2676 1.00000 RENAISSANCE HOLDING COMPANY PO BOX 30381 LANSING MI 48909 412177193 HOLDING COMPANY MI RENAISSNCE HEALTH SERVICE CORPORATION C -67101 2745206 0.06200 RENAISSANCE LIFE & HEALTH INSURANCE COMPANY OF AMERICA PO BOX 30416 LANSING MI 489097916 470397286 INSURANCE IN RENAISSANCE HOLDING COMPANY C RENAISSANCE HEALTH INSURANCE COMPANY OF NEW YORK PO BOX 30416 LANSING MI 48909 134098096 INSURANCE NY RENAISSANCE HOLDING COMPANY C RENAISSANCE HEALTH NETWORKS 4100 OKEMOS RD PO BOX 30381 LANSING MI 489097881 113774096 PPO NETWORK MI RENAISSANCE HOLDING COMPANY C RENAISSANCE DENTAL NETWORK LLC 4100 OKEMOS RD PO BOX 30381 LANSING MI 48909 421749772 PPO NETWORK MI RENAISSANCE HEALTH NETWORKS LLC C DENTAL WELLNESS NETWORK LLC 1540 W EDGEWOOD SUITE B INDAINAPOLIS IN 46217 010862825 PPO NETWORK MI RENAISSANCE HEALTH NETWORKS LLC C FORE HOLDING CORPORATION 240 VENTURE CIRCLE NASHVILLE TN 37228 204116122 EMPLOYEE BENEFITS TN DELTA DENTAL OF TENNESSEE C TML LLC 4100 OKEMOS ROAD PO BOX 30381 LANSING MI 489097881 262403888 CLEARING HOUSE MI RENAISSNCE HEALTH SERVICE CORPORATION C 0 1 0 1 0 0 0 0 0 0 1 1 0 1 1 1 0 0 DENTAL CHOICE INC K 384400 ACTUAL COST DELTA DENTAL OF NORTH CAROLINA D 1600000 ACTUAL COST DELTA DENTAL PLAN OF MICHIGAN L 311021 ACTUAL COST RENAISSANCE HOLDING COMPANY B 371000 ACTUAL COST