2012-11-12T14:13:15-06:00 2011-12-31 830331229 MCGEE HEARNE & PAIZ LLP P O BOX 1088 CHEYENNE WY 82003 990 2011-01-01 830209667 DELTA DENTAL PLAN OF WYOMING DELT 3076323313 6234 YELLOWSTONE RD CHEYENNE WY 82009 KERRY HALL 3076323313 2012-10-18 1 RUSSELL E HAY P00028728 3076342151 2011 2016-02-24 21:20:13Z X DELTA DENTAL OF WYOMING KERRY HALL 6234 YELLOWSTONE RD CHEYENNE WY 82009 31746585 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 DENTIST ALIKE WITH THE GOAL OF MAKING AFFORDABLE DENTAL CARE AVAILABLE TO ALL WYOMING EMPLOYEES. 13 6 9 0 0 0 0 0 27230646 28721931 374953 645710 -3234 -12984 27602365 29354657 0 0 0 0 752285 819554 0 0 0 26225618 27261041 26977903 28080595 624462 1274062 9484821 10428867 3036368 3322345 6448453 7106522 TO BE THE LEADING WYOMING PROVIDER OF HIGH QUALITY DENTAL CARE PROGRAMS WHICH ARE RESPONSIVE TO SUBSCRIBERS, PURCHASERS AND PARTICIPATING DENTIST ALIKE WITH THE GOAL OF MAKING AFFORDABLE DENTAL CARE AVAILABLE TO ALL WYOMING EMPLOYEES. 0 0 27230853 28721931 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. 27230853 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 0 1 1219 0 1 9 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 ED CLARK 1.00 X X 5066 0 0 DR BRUCE HOLWELL 1.00 X X 2044 0 0 JEFF MARSH 1.00 X X 2356 0 1320 DR JAMES GILMAN 1.00 X X 1432 0 0 DR BILL GERN 1.00 X 1808 0 0 BRUCE HINCHEY 1.00 X 1284 0 1320 DR SCOTT HOUFEK 1.00 X 1924 0 0 DR BYRON KILLPACK 1.00 X 1404 0 0 ROXANNE OSTLUND 1.00 X 1816 0 990 BOB PALMER 1.00 X 2124 0 0 DR ROY PAULSON 1.00 X 1756 0 0 DR ROBERT TYRRELL 1.00 X 1948 0 0 ROD CHISHOLM 1.00 X 512 0 0 KERRY HALL 40.00 X 193249 0 93776 STACY ZASTOUPIL 40.00 X 99999 0 25036 DR EARL KINCHELOE 5.00 X 59589 0 1320 DR JAMES HOAG 1.00 X 3103 0 1320 381414 0 125082 1 0 1 0 DELTA DENTAL OF SOUTH DAKOTA 720 N EUCLID AVE PIERRE SD 57501 CLAIMS PROCESSING & SUPPLIES 429045 1 DENTAL PREMIUMS & ADMI 524114 28721931 28721931 28721931 210734 210734 2826904 2391928 434976 434976 434976 OTHER THAN TEMPORARY L 524114 -12984 -12984 -12984 29354657 28721931 0 632726 381414 204056 177358 221706 118613 103093 98867 52894 45973 77709 41574 36135 39858 21324 18534 2646 595 2051 27775 6249 21526 32765 32765 104456 13057 91399 74882 39313 35569 44864 16600 28264 17555 5003 12552 74590 21258 53332 58 58 9166 3575 5591 12838 4493 8345 DENTAL CLAIMS PAID 25633370 25633370 COMMISSIONS 582109 582109 COMPUTER - CLAIMS 326729 295690 31039 POSTAGE & SHIPPING 112131 80734 31397 205107 90288 114819 28080595 27230853 849742 0 665744 1675139 322924 334559 1921062 1879009 15512 33938 266050 244780 13212 21270 4548891 4415858 1979565 2054547 17911 14547 9484821 10428867 923232 955173 148701 255248 1964435 2111924 3036368 3322345 X 6448453 7106522 6448453 7106522 9484821 10428867 X 1274062 -615993 X X 0 1 1 X 0 29355 29355 0 211415 193970 17445 25280 21455 3825 21270 INVESTMENT IN LIFE INSURANCE CONTRACT 1330356 F CERTIFICATE OF DEPOSIT 724191 F 2054547 DEFERRED COMPENSATION PAYABLE 760958 MEMBER REPURCHASE PLAN PAYABLE 1197316 RATE STABILIZATION RESERVE 153650 2111924 29354657 28080595 1274062 -615993 -615993 658069 28722440 0 28722440 632217 632217 29354657 28031871 0 28031871 32765 15959 48724 28080595 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: 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 FOR YEARS BEFORE 2008. PART XII, LINE 4B - OTHER ADJUSTMENTS: INVESTMENT INCOME 210,225. GAIN ON SALE OF INVESTMENTS 434,976. OTHER THAN TEMPORARY LOSSES -12,984. PART XIII, LINE 4B - OTHER ADJUSTMENTS: NET AMORTIZATION OF PREMIUMS AND DISCOUNTS 15,959. AUDITED FINANCIALS CONTAIN SEPERATE "FINANCIAL INCOME" COMPONENT. THIS COMPONENT TOTALS $583,493 WHICH CONSISTS OF: $632,217 FROM PART XII AND $48,724 FROM PART XIII. X 1 1 X X 0 1 0 0 0 0 0 0 0 KERRY HALL 180000 0 10000 0 3249 0 75897 0 17879 0 287025 0 283085 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 15, 2011 AND 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 $60,525 IN 2011. DR. EARL KINCHELOE PARTICIPATED IN A SUPPLEMENT NONQUALIFIED RETIREMENT PLAN BUT RECEIVED $0 IN 2011. DR ED CLARK BOARD MEMBER 276731 DENTIST WHO PARTICIPATES IN THE ORGANIZATION'S PROVIDER NETWORK AND RECEIVES REIMBURSEMENT FOR PATIENT CLAIMS FROM THE ORGANIZATION. 0 DR BYRON KILLPACK BOARD MEMBER 336827 DENTIST WHO PARTICIPATES IN THE ORGANIZATION'S PROVIDER NETWORK AND RECEIVES REIMBURSEMENT FOR PATIENT CLAIMS FROM THE ORGANIZATION. 0 DR ROY PAULSON BOARD MEMBER 220048 DENTIST WHO PARTICIPATES IN THE ORGANIZATION'S PROVIDER NETWORK AND RECEIVES REIMBURSEMENT FOR PATIENT CLAIMS FROM THE ORGANIZATION. 0 DR EARL KINCHELOE VP PROFESSIONAL RELATIONS 436042 DENTIST WHO PRACTICES DENTISTRY WITH SON AND PARTICIPATES IN THE ORGANIZATION'S PROVIDER NETWORK AND RECEIVES REIMBURSEMENT FOR PATIENT CLAIMS FROM THE ORGANIZATION. 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 PEOPLE) 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 2011 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 COMPLILED BY AN INDEPENDENT COMPENSATION CONSULTANT AND CONTEMPORANEOUS DOCUMENTATION AND RECORDKEEPTING 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 15, 2011 AND 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 ED CLARK - 5211 YELLOWSTONE ROAD, CHEYENNE, WY 82009. DR BRUCE HOLWELL - BOX 5058, SHERIDAN, WY 82801. JEFF MARSH - 1749 WEST 15TH AVE, TORRINGTON, WY 82240. DR. JAMES GILMAN - 209 S. 7TH, WORLAND, WY 82401. DR. BILL GERN - 1000 E. UNIVERSITY, DEPT 3355, LARAMIE, WY 82071. DR. JAMES HOAG - 814 S. DAVID ST., CASPER, WY 82601. 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 - 500 S. GILLETTE AVE, SUITE 1100, GILLETTE, WY 82716. DR. ROY PAULSON - 102 N. KENWOOD, CASPER, WY 82601. DR. ROBERT TYRRELL - 1702 ANTELOPE, KEMMERER, WY 83101. ROD CHISHOLM - 1051 BONITA DR., LARAMIE, WY 82072. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -615,993. PART XI, LINE 2C: DELTA DENTAL HAS A COMMITTEE THAT OVERSEES THE AUDIT