2012-11-13T15:57:33-06:00 2011-12-31 421229486 BROOKS LODDEN PC 1441 29TH STREET STE 305 WEST DES MOINES IA 502661357 990 2011-01-01 420959302 DELTA DENTAL OF IOWA DELT 5152615500 9000 NORTHPARK DRIVE JOHNSTON IA 50131 CHERYL HARDING 5152615500 2012-11-13 1 BRENT L ALEXANDER P00075113 5152237300 2011 2016-02-24 21:20:13Z DONN HUTCHINS 9000 NORTHPARK DRIVE JOHNSTON IA 50131 79468700 0 X WWW.DELTADENTALIA.COM X 1970 IA DENTAL HEALTH CARE: TO IMPROVE THE ORAL HEALTH OF THE PEOPLE WE SERVE. THIS IS ACCOMPLISHED THROUGH THE PROVISION OF DENTAL INSURANCE AND PUBLIC HEALTH CONTRIBUTIONS THAT FOCUS ON ACCESS TO ORAL HEALTH SERVICES AND EDUCATION RELATED TO GOOD ORAL HEALTH BEHAVIORS. 9 3 79 0 101066 0 0 0 67111304 72381744 976111 1290713 130498 101066 68217913 73773523 1858714 2880371 46244699 48289991 7419331 7595505 0 0 0 9081213 9766543 64603957 68532410 3613956 5241113 53430840 59976161 11407284 12229165 42023556 47746996 DENTAL HEALTH CARE: TO IMPROVE THE ORAL HEALTH OF THE PEOPLE WE SERVE. THIS IS ACCOMPLISHED THROUGH THE PROVISION OF DENTAL INSURANCE AND PUBLIC HEALTH CONTRIBUTIONS THAT FOCUS ON ACCESS TO ORAL HEALTH SERVICES AND EDUCATION RELATED TO GOOD ORAL HEALTH BEHAVIORS. 0 0 61890157 2880371 72381744 SINCE 1970, DELTA DENTAL OF IOWA HAS EXPANDED ACCESS TO DENTAL CARE BY PROVIDING AFFORDABLE, NETWORK BASED DENTAL BENEFITS PLANS TO IOWA EMPLOYERS AND INDIVIDUALS THAT RESULT IN LONG-TERM COST SAVINGS AND SUPPORT GOOD ORAL HEALTH. DELTA DENTAL OF IOWA'S DENTAL BENEFIT PLANS STRIVE TO INCORPORATE THE CURRENT BEST PRACTICES IN DENTAL SCIENCE. DELTA DENTAL IS COMMITTED TO ITS VISION OF IMPROVING THE ORAL HEALTH OF THE PEOPLE AND COMMUNITIES IT SERVES. DELTA DENTAL FULFILLS ITS NOT-FOR-PROFIT VISION BY ACTIVELY PARTICIPATING IN THE COMMUNITIES IT SERVES AS A CHAMPION AND MAJOR FUNDER OF ORAL HEALTH INITIATIVES IN THE STATE OF IOWA. DELTA DENTAL INVESTS IN ORAL HEALTH PROJECTS THAT MEET THE NEEDS OF UNDERSERVED POPULATIONS AND THAT FOCUS ON ACCESS TO CARE, PREVENTION, EDUCATION AND RESEARCH. 61890157 0 0 0 0 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 1 0 1 0 0 0 0 0 1 1 0 0 1 15811 0 79 1 1 1 0 0 0 0 0 X 9 3 1 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 X CHERYL HARDING 5152615500 9000 NORTHPARK DRIVE JOHNSTON IA 50131 W BRYAN CLEMONS II DDS 1.60 X 8200 0 0 CHARLES EDWARD BROWN 1.60 X 6200 0 0 ANNE HENNESSEY DDS 1.60 X 12500 0 0 JOHN KEARNS DDS 2.20 X 500 600 11500 MERRITT KRAUSE 2.20 X 13100 0 0 JEFF PLAGGE 1.60 X 8750 200 8250 RENIE NEUBERGER 1.60 X 12400 0 0 TOM ALLER 2.50 X 17100 0 0 WILLIAM WEVER DDS 1.60 X 7300 0 0 DONN HUTCHINS 40.00 X X 600748 0 153321 CHERYL HARDING 40.00 X 332342 0 71341 GREGORY SHIREMAN 40.00 X 343184 0 32076 RICHARD RUSSELL 40.00 X 234666 0 51194 ED SCHOOLEY DDS 40.00 X 206179 0 20325 SHERRY MALY 40.00 X 149817 0 18227 SHERRY PERKINS 40.00 X 153158 0 31549 BRENDA LOWE 40.00 X 148429 0 18366 SUZANNE HECKENLAIBLE 40.00 X 126182 0 29860 2380755 800 446009 15 0 1 0 UNIVERSITY OF IOWA 322 DENTAL SCIENCE BLDG S IOWA CITY IA 52242 DENTAL SERVICES 3472931 CONSAMUS AND HAMPTON DENTAL CLINIC PLC 3324 ORION DR AMES IA 50010 DENTAL SERVICES 1559673 APPLEWHITE DENTAL IOWA PC 1340 DELHI ST DUBUQUE IA 52001 DENTAL SERVICES 1468471 DENTAL ASSOCIATES PC 3700 WESTOWN PKWY WEST DES MOINES IA 50266 DENTAL SERVICES 1405951 IOWA ORAL & MAXILL SURGEONS PC 1469 29TH ST WEST DES MOINES IA 50266 DENTAL SERVICES 1338223 495 PREMIUMS EARNED 524114 62695297 62695297 ADMINISTRATIVE SERVICE 524292 9686447 9686447 72381744 1205043 1205043 5780847 5695177 85670 85670 85670 MANAGEMENT FEES 541610 101066 101066 101066 73773523 72381744 101066 1290713 2880371 2880371 48289991 48289991 2380755 298246 2082509 3374336 2214651 1159685 549402 146851 402551 911364 616148 295216 379648 194027 185621 81968 1368 80600 107545 45 107500 57501 57501 163523 163523 1080976 595898 485078 475183 434273 40910 1639697 1286930 352767 1312596 1312596 325046 325046 155528 85431 70097 72303 25902 46401 319716 61892 257824 170066 170066 BROKER COMMISSIONS 2880895 2880895 PREMIUM TAXES 519153 519153 DDPA DUES 209572 209572 CIVIC AND CHARITABLE CO 102720 22547 80173 92555 22942 69613 68532410 61890157 6642253 0 2458670 4861869 752617 604056 2043166 1667768 10237709 1615978 8701040 8621731 38812789 43505201 226126 241927 436432 473609 53430840 59976161 6671677 7912287 4735607 4316878 11407284 12229165 X 0 0 475819 475819 41547737 47271177 42023556 47746996 53430840 59976161 X 5241113 482327 X X 0 1 1 X 0 2665500 2665500 5099092 180593 4918499 2473117 1435385 1037732 8621731 UNEARNED PREMIUMS 1325951 CLAIMS UNPAID 2779831 OTHER POLICY RESERVES 211096 4316878 73773523 68532410 5241113 482327 482327 5723440 223683098 150174165 150174165 73508933 163524 101066 264590 73773523 218441985 150174165 150174165 68267820 163524 101066 264590 68532410 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: PART X: DELTA DENTAL OF IOWA IS ORGANIZED AS A NONPROFIT DENTAL CARE PLAN FOR FEDERAL INCOME TAX PURPOSES UNDER SECTION 501(C)(4) OF THE INTERNAL REVENUE CODE AND, AS SUCH, DOES NOT PAY FEDERAL INCOME TAXES. THE COMPANY IS EXEMPT FROM STATE INCOME TAXES. THE COMPANY EVALUATES TAX POSITIONS TAKEN OR EXPECTED TO BE TAKEN IN THE COURSE OF PREPARING ITS TAX RETURNS TO DETERMINE WHETHER IT IS "MORE LIKELY THAN NOT" THAT EACH TAX POSITION WOULD BE SUSTAINED UPON EXAMINATION BY A TAXING AUTHORITY BASED ON THE TECHNICAL MERITS OF THE POSITION. TAX POSITIONS NOT DEEMED TO MEET THE MORE-LIKELY-THAN-NOT THRESHOLD WOULD BE RECORDED AS A TAX BENEFIT OR EXPENSE IN THE CURRENT YEAR. DURING THE YEARS ENDED DECEMBER 31, 2011 AND 2010, THE COMPANY DID NOT RECORD ANY SUCH TAX BENEFIT OR EXPENSE IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. NO EXAMINATIONS ARE IN PROGRESS OR ANTICIPATED AT THIS TIME. PART XII, LINE 2D - OTHER ADJUSTMENTS: ADMINISTRATIVE SERVICE CLAIMS (NETTED WITH REVENUE) 150,174,165. PART XII, LINE 4B - OTHER ADJUSTMENTS: MANAGEMENT FEES (NETTED WITH EMPLOYEE BENEFITS) 101,066. PART XIII, LINE 2D - OTHER ADJUSTMENTS: ADMINISTRATIVE SERVICE CLAIMS (NETTED WITH REVENUE) 150,174,165. PART XIII, LINE 4B - OTHER ADJUSTMENTS: MANAGEMENT FEES - NETTED WITH EXPENSES FOR FINANCIALS 101,066. 1 DELTA DENTAL OF IOWA FOUNDATION 9000 NORTHPARK DRIVE JOHNSTON IA 50131 260762771 501(C)(3) 1503467 CONTRIBUTION TO DELTA DENTAL OF IOWA FOUNDATION TO SUPPORT & IMPROVE THE ORAL HEALTH OF IOWANS. COMMUNITY FOUNDATION OF GREATER DES MOINES 1915 GRAND AVE DES MOINES IA 50309 426139033 501(C)(3) 50000 CONTRIBUTION TO CFGDM FOR THE DDIA DONOR ADVISED FUND. THE DONOR ADVISED FUND IS USED FOR THE REPAYMENT OF DENTAL EDUCATION DEBT FOR A DENTIST WHO AGREES TO ESTABLISH AN OFFICE IN A RURAL, UNDERSERVED AREA. PART I, QUESTION 1: IN 2011, DELTA DENTAL OF IOWA GRANTED $50,000 TO THE COMMUNITY FOUNDATION OF GREATER DES MOINES. DELTA DENTAL OF IOWA MAINTAINS A DONOR ADVISED FUND AT THE COMMUNITY FOUNDATION OF GREATER DES MOINES FOR THE PURPOSE OF AWARDING LOAN REPAYMENT AWARDS TO DENTISTS WHO AGREE TO PRACTICE IN AN UNDERSERVED AREA IN THE STATE OF IOWA AND TO DEDICATE A PORTION OF THEIR PRACTICE TO LOW INCOME PATIENTS. DELTA DENTAL OF IOWA ADVISES THE COMMUNITY FOUNDATION OF GREATER DES MOINES ON HOW TO AWARD THIS MONEY AND THE COMMUNITY FOUNDATION OF GREATER DES MOINES ONLY GRANTS THIS MONEY TO DENTISTS IN THE STATE OF IOWA. THE COMMUNITY FOUNDATION OF GREATER DES MOINES AND DELTA DENTAL OF IOWA MAINTAIN RECORDS TO SUBSTANTIATE THE AMOUNT OF GRANTS, THE GRANTEES' ELIGIBILITY AND THE SELECTION CRITERIA. DELTA DENTAL OF IOWA ALSO MAKES GRANTS TO THE DELTA DENTAL OF IOWA FOUNDATION. THE DELTA DENTAL OF IOWA FOUNDATION MAINTAINS RECORDS TO SUBSTANTIATE THE AMOUNT OF GRANTS, THE GRANTEES' ELIGIBILITY AND THE SELECTION CRITERIA. X 1 1 X X X X X 0 1 0 1 0 1 0 0 0 DONN HUTCHINS 409350 0 174832 0 16566 0 140234 0 13087 0 754069 0 0 0 CHERYL HARDING 240811 0 87722 0 3809 0 52012 0 19329 0 403683 0 0 0 GREGORY SHIREMAN 231172 0 107791 0 4221 0 19600 0 12476 0 375260 0 0 0 RICHARD RUSSELL 168660 0 61969 0 4037 0 31943 0 19251 0 285860 0 0 0 ED SCHOOLEY DDS 139584 0 64973 0 1622 0 16305 0 4020 0 226504 0 0 0 SHERRY MALY 121548 0 26786 0 1483 0 11876 0 6351 0 168044 0 0 0 SHERRY PERKINS 113501 0 37961 0 1696 0 12298 0 19251 0 184707 0 0 0 BRENDA LOWE 48110 0 98665 0 1654 0 11895 0 6471 0 166795 0 0 0 SUZANNE HECKENLAIBLE 100509 0 23789 0 1884 0 10609 0 19251 0 156042 0 0 0 PART I, LINE 1A TAX GROSS UP PAYMENTS ARE RELATED TO TAXABLE FRINGE BENEFITS INCLUDED AS COMPENSATION FOR ALL COMPANY EMPLOYEES INCLUDING THE PERSONS LISTED IN PART VII, SECTION A, LINE 1. THE PAYMENTS REPRESENT 1% OR LESS OF COMPENSATION FOR THE INDIVIDUALS. PART I, LINE 4B OFFICERS OF THE COMPANY PARTICIPATE IN A SEC. 457(F) PLAN. THE COMPANY MAKES A CONTRIBUTION TO THE PLAN ANNUALLY ON BEHALF OF THE OFFICERS. THIS CONTRIBUTION IS A PERCENTAGE OF SALARY AND IS SET AND APPROVED BY THE EXECUTIVE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS. THE OFFICERS CANNOT ACCESS THE FUNDS UNTIL RETIREMENT, LEAVING THE COMPANY, OR DEATH. OFFICERS WHO RECEIVED DEPOSITS IN 2011 AND AMOUNTS ARE: DONN HUTCHINS $120,634 CHERYL HARDING $ 32,427 GREG SHIREMAN $ 31,815 RICHARD RUSSELL $ 15,634 PART I, LINE 5 ONE EMPLOYEE OF THE COMPANY HAS COMPENSATION CONTINGENT ON REVENUES. THE INDIVIDUAL IS AN ACCOUNT EXECUTIVE OF THE COMPANY WHO RECEIVES COMMISSIONS BASED ON SALES OF GROUP BUSINESS. THIS ACCOUNT EXECUTIVE IS RESPONSIBLE FOR SELLING NEW BUSINESS. PART I, LINE 6 CONSISTENT WITH THE COMPANY'S TOTAL COMPENSATION POLICY, THE OFFICERS AND KEY EMPLOYEES, ALONG WITH ALL EMPLOYEES OF THE COMPANY, PARTICIPATE IN A COMPANY INCENTIVE COMPENSATION PLAN. THIS PLAN CONTAINS EIGHT METRICS WHICH REPRESENT KEY GOALS FOR THE PLAN YEAR. AN OVERALL WEIGHTED SCORE IS CALCULATED. A BONUS WILL BE PAID IF THE COMPANY MEETS A RANGE OF GOAL ACCOMPLISHMENTS FOR THE YEAR. THE AMOUNT OF THE BONUS IS BASED ON THE TOTAL SCORE. ONE OF THESE METRICS IS PROFITABILITY, WHICH IS DEFINED AS "TOTAL NET GAIN IN DOLLARS PRIOR TO ORAL HEALTH CONTRIBUTIONS FOR THE FISCAL YEAR PER AUDITED FINANCIAL RESULTS." JOHN KEARNS DDS DIRECTOR 226167 INDEPENDENT CONTRACTOR - PAYMENTS FROM DDIA FOR DENTAL SERVICES 0 ANNE HENNESSEY DDS DIRECTOR 147297 INDEPENDENT CONTRACTOR - PAYMENTS FROM DDIA FOR DENTAL SERVICES 0 WILLIAM WEVER DDS DIRECTOR 113650 INDEPENDENT CONTRACTOR - PAYMENTS FROM DDIA FOR DENTAL SERVICES 0 MERRITT KRAUSE DDIA DIRECTOR & OFFICER OF EMPLOYER WHO PURCHASES DENTAL BENEFITS FROM DDIA 278468 PAYMENTS TO DDIA FOR ADMINISTRATIVE SERVICES 0 CHARLES EDWARD BROWN DDIA DIRECTOR & OFFICER OF EMPLOYER WHO PURCHASES DENTAL BENEFITS FROM DDIA 199971 PAYMENTS TO DDIA FOR ADMINISTRATIVE SERVICES 0 FORM 990, PART VI, SECTION A, LINE 2 TWO DIRECTORS HAVE A BUSINESS RELATIONSHIP. JEFF PLAGGE IS PRESIDENT OF A COMPANY THAT PURCHASES BENEFITS FROM A BROKER COMPANY IN WHICH MERRITT KRAUSE SERVES AS PRESIDENT. MR. PLAGGE MAKES DECISIONS REGARDING BENEFIT PURCHASES. FORM 990, PART VI, SECTION A, LINE 6 THE MEMBERS OF THE CORPORATION CONSIST OF THE PROVIDERS (PARTICIPATING DENTISTS), AND SUBSCRIBER DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7A DECISIONS OF THE GOVERNING BODY ARE NOT SUBJECT TO APPROVAL BY THE MEMBERSHIP WITH THE EXCEPTION OF CHANGES TO THE ARTICLES OF INCORPORATION. THOSE CHANGES MUST BE APPROVED BY THE MEMBERSHIP. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 AND ALL RELATED SCHEDULES WERE REVIEWED BY BOTH THE MANAGEMENT OF THE COMPANY AND THE BOARD OF DIRECTORS PRIOR TO FILING. THE FORM 990 WAS REVIEWED BY MANAGEMENT OF THE COMPANY PRIOR TO PRESENTATION TO THE BOARD. THE MEMBERS OF THE MANAGEMENT TEAM WHO REVIEWED THE FORM 990 WERE THE CEO, COO, COMPLIANCE MANAGER, AND CONTROLLER. AN ELECTRONIC COPY OF THE FORM 990 WAS PROVIDED TO ALL BOARD MEMBERS PRIOR TO THE BOARD MEETING HELD ON SEPTEMBER 20, 2012. ALL MEMBERS OF THE BOARD REVIEWED THE FORM 990 AND RELATED SCHEDULES PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C THE COMPLIANCE MANAGER, ON BEHALF OF THE GOVERNANCE COMMITTEE, CONDUCTS AN ANNUAL CONFLICT OF INTEREST REVIEW FOR COMPLIANCE WITH FEDERAL AND STATE LAW. THE REVIEW INCLUDES ALL OFFICERS, DIRECTORS, AND KEY EMPLOYEES. COMPLETED CONFLICT OF INTEREST QUESTIONNAIRES AND DISCLOSURES ARE COMPARED TO THE GROUP FOR POTENTIALLY CONFLICTING TRANSACTIONS, BUSINESS AND FAMILY RELATIONSHIPS, AND AFFILIATIONS. ANNUAL COMPENSATION, REIMBURSEMENTS, BENEFIT PAYMENTS, AND OTHER TRANSACTIONS ARE REVIEWED FOR APPROPRIATENESS. A WRITTEN REPORT OF THE FINDINGS IS PRESENTED TO THE GOVERNANACE COMMITTEE, BOARD OF DIRECTORS AND SENIOR MANAGEMENT. SOLUTIONS TO POTENTIAL CONFLICTS ARE DISCUSSED AND DOCUMENTED IN THE BOARD OF DIRECTOR'S MEETING MINUTES. FORM 990, PART VI, SECTION B, LINE 15 ON A BI-ANNUAL BASIS, DELTA DENTAL OF IOWA DOES A MARKET PRICE AND BENCHMARKING COMPARISON OF THE COMPENSATION OF THE LEADERSHIP TEAM AND THE STAFF. THIS ANALYSIS IS PERFORMED BY AN INDEPENDENT THIRD PARTY. THIS ANALYSIS INCLUDES THE USE OF DATA AS TO COMPARABLE COMPENSATION FOR SIMILARLY QUALIFIED PERSONS IN FUNCTIONALLY COMPARABLE POSITIONS AT SIMILARLY SITUATED ORGANIZATIONS. THE DOCUMENTED RESULTS AND RECOMMENDATIONS OF THIS ANALYSIS ARE PRESENTED TO THE BOARD OF DIRECTORS. THE BOARD OF DIRECTORS REVIEWS THE DOCUMENTATION AND APPROVES THE COMPENSATION. THESE DECISIONS ARE DOCUMENTED IN THE MINUTES OF THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION C, LINE 19 DELTA DENTAL OF IOWA'S ARTICLES OF INCORPORATION BECOME A MATTER OF PUBLIC RECORD WHEN THEY ARE FILED WITH THE IOWA SECRETARY OF STATE. THE FINANCIAL STATEMENTS BECOME A MATTER OF PUBLIC RECORD WHEN THEY ARE FILED WITH THE IOWA INSURANCE DIVISION. BOTH AGENCIES HAVE ONLINE PUBLIC VIEWING ACCESS. THE CONFLICT OF INTEREST POLICY IS NOT FILED WITH THE STATE AGENCIES; HOWEVER, IT WOULD BE MADE AVAILABLE UPON REQUEST. ALL GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE AVAILABLE FROM THE ORGANIZATION UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED GAINS ON INVESTMENTS: 482,327. FORM 990, PART XI, LINE 2C: THE ORGANIZATION HAS A FINANCE AND AUDIT COMMITTEE THAT HAS RESPONSIBILITY FOR SELECTION OF THE INDEPENDENT ACCOUNTANT AND OVERSIGHT OF THE AUDIT. THE BOARD OF DIRECTORS APPROVES THE ANNUAL APPOINTMENT OF THE INDEPENDENT ACCOUNTANT. FORM 990, PART IV, LINE 35B: THIS QUESTION IS ANSWERED AS "NO" BECAUSE THE ORGANIZATION DID NOT RECEIVE ANY OF THE "SPECIFIED PAYMENTS" AS OUTLINED IN IRC SEC 512(B)(13). PRIMARY ACTIVITY OF DELTA DENTAL PLAN OF IOWA FOUNDATION: SCHEDULE R, PART II, COLUMN B: DELTA DENTAL OF IOWA'S VISION IS TO IMPROVE THE ORAL HEALTH OF THOSE WE SERVE. AN AMOUNT IS SET ASIDE EACH YEAR TO FUND THIS MISSION. THE AMOUNT IS DETERMINED BY THE PERFORMANCE AND FINANCIAL STRENGTH OF THE COMPANY. AFTER THE AUDITED FINANCIALS ARE COMPLETE, THE AMOUNT IS PAID TO THE DELTA DENTAL OF IOWA FOUNDATION. THE DELTA DENTAL OF IOWA FOUNDATION IS A SEC. 501(C)(3) ORGANIZATION AND IS A TYPE 1 SUPPORTING ORGANIZATION UNDER SEC. 509(A)(3). IT IS THE RESPONSIBILITY OF THE FOUNDATION TO DISTRIBUTE THE MONIES CONSISTENT WITH IT'S MISSION AND FOUNDING DOCUMENTS. THE MISSION OF THE DELTA DENTAL OF IOWA FOUNDATION IS TO SUPPORT AND IMPROVE THE ORAL HEALTH OF IOWANS. THE FOUNDATION WILL PROVIDE FUNDS TO OTHER SEC. 501(C)(3) ORGANIZATIONS, GOVERNMENTS, OR ACADEMIC INSTITUTIONS THAT ARE UNDERTAKING PROJECTS THAT SUPPORT AND IMPROVE THE ORAL HEALTH OF IOWANS. THE FOUNDATION WILL PROVIDE FUNDS TO OTHER TAX-EXEMPT ORGANIZATIONS THROUGH THEIR GRANTS PROGRAM THAT ALIGN WITH THE PROJECTS OF ACCESS TO CARE, RESEARCH, EDUCATION AND PREVENTION. THE AMOUNT CONTRIBUTED TO THE FOUNDATION IN 2011 WAS $1,503,467. ADDITIONALLY, DELTA DENTAL OF IOWA PROVIDES MANAGEMENT SERVICES FOR THE FOUNDATION. THIS INCLUDES DUTIES PERFORMED BY THE CHIEF EXECUTIVE OFFICER AND CHIEF OPERATING OFFICER. THE EXECUTIVE DIRECTOR OF THE FOUNDATION IS THE DIRECTOR OF GOVERNMENT AND COMMUNITY RELATIONS FOR DELTA DENTAL OF IOWA. ALSO, DELTA DENTAL OF IOWA PROVIDES SOME ACOUNTING FUNCTIONS. THE FOUNDATION REIMBURSES DELTA DENTAL OF IOWA FOR ALL STAFF CHARGES RELATED TO THE FOUNDATION. THE AMOUNT REIMBURSED TO DELTA DENTAL OF IOWA IN 2011 WAS $87,132 FOR MANAGEMENT FEES AND $37,305 FOR OTHER EXPENSES. PRIMARY ACTIVITY OF VERATRUS BENEFIT SOLUTIONS, INC.: SCHEDULE R, PART IV, COLUMN B: VERATRUS BENEFIT SOLUTIONS, INC. (VERATRUS) IS A FOR-PROFIT CORPORATION AND A WHOLLY-OWNED SUBSIDIARY OF DELTA DENTAL OF IOWA. VERATRUS WAS ORGANIZED TO DISTRIBUTE THE DELTA VISION PRODUCT. DELTA DENTAL OF IOWA INVESTED $125,000 IN PAID-IN CAPITAL IN VERATRUS DURING 2011. DELTA DENTAL OF IOWA COLLECTS PREMIUMS FROM GROUPS FOR VISION COVERAGE AND TRANSFERS THIS PREMIUM TO VERATRUS. IN 2011, DELTA DENTAL OF IOWA TRANSFERRED $480,986 TO VERATRUS FOR PREMIUMS COLLECTED ON THEIR BEHALF. IN ADDITION, DELTA DENTAL OF IOWA PROVIDES MANAGEMENT SERVICES TO VERATRUS. VERATRUS REIMBURSES DELTA DENTAL OF IOWA FOR ALL STAFF CHARGES RELATED TO VERATRUS. THE AMOUNT REIMBURSED TO DELTA DENTAL OF IOWA IN 2011 WAS $101,066 FOR MANAGEMENT FEES AND $48,227 FOR OTHER EXPENSES. DELTA DENTAL OF IOWA ALSO PURCHASES VISION BENEFITS FROM VERATRUS FOR DDIA EMPLOYEES. THE AMOUNT PAID TO VERATRUS IN 2011 FOR VISION BENEFITS FOR DDIA EMPLOYEES WAS $10,608. DELTA DENTAL OF IOWA FOUNDATION 9000 NORTHPARK DRIVE JOHNSTON IA 50131 260762771 CHARITABLE ORGANIZATION TO SUPPORT AND IMPROVE THE ORAL HEALTH OF IOWANS. IA 501(C)(3) LINE 11A, I DELTA DENTAL OF IOWA 1 VERATRUS BENEFIT SOLUTIONS INC 9000 NORTHPARK DRIVE JOHNSTON IA 50131 271584394 FOR-PROFIT CORPORATION ORGANIZED TO DISTRIBUTE THE DELTA VISION PRODUCT. IA DENTAL DENTAL OF IOWA C -109200 315672 1.00000 0 1 0 0 0 0 0 0 0 0 1 1 1 1 0 1 1 0 DELTA DENTAL OF IOWA FOUNDATION B 1503467 SEE PART VII - SUPPLEMENTAL INFO. DELTA DENTAL OF IOWA FOUNDATION N 87132 SEE PART VII - SUPPLEMENTAL INFO. DELTA DENTAL OF IOWA FOUNDATION P 37305 SEE PART VII - SUPPLEMENTAL INFO. DELTA DENTAL OF IOWA FOUNDATION Q 300000 CASH TRANSFERRED FROM DDIA TO FDN VERATRUS BENEFIT SOLUTIONS INC B 125000 SEE PART VII - SUPPLEMENTAL INFO. VERATRUS BENEFIT SOLUTIONS INC N 101066 SEE PART VII - SUPPLEMENTAL INFO. VERATRUS BENEFIT SOLUTIONS INC Q 480986 SEE PART VII - SUPPLEMENTAL INFO. VERATRUS BENEFIT SOLUTIONS INC P 48227 SEE PART VII - SUPPLEMENTAL INFO. VERATRUS BENEFIT SOLUTIONS INC L 10608 SEE PART VII - SUPPLEMENTAL INFO. METHOD OF DETERMINING AMOUNT INVOLVED - FORM 990, SCHEDULE R, PART V, LINE 2(8), COLUMN D: ACTUAL COST OF INVOICES PAID BY DDIA ON BEHALF OF VERATRUS BENEFIT SOLUTIONS, INC. METHOD OF DETERMINING AMOUNT INVOLVED - FORM 990, SCHEDULE R, PART V, LINE 2(9), COLUMN D: VISION PREMIUMS PAID TO VERATRUS BENEFIT SOLUTIONS, INC. FOR DDIA EMPLOYEES. METHOD OF DETERMINING AMOUNT INVOLVED - FORM 990, SCHEDULE R, PART V, LINE 2(1), COLUMN D: PERCENTAGE OF REVENUE BASED ON BOARD APPROVED POLICY METHOD OF DETERMINING AMOUNT INVOLVED - FORM 990, SCHEDULE R, PART V, LINE 2(2), COLUMN D: FEES CHARGED TO DELTA DENTAL OF IOWA FOUNDATION BASED ON HOURS WORKED METHOD OF DETERMINING AMOUNT INVOLVED - FORM 990, SCHEDULE R, PART V, LINE 2(3), COLUMN D: ACTUAL COST OF INVOICES PAID BY DDIA ON BEHALF OF DELTA DENTAL OF IOWA FOUNDATION METHOD OF DETERMINING AMOUNT INVOLVED - FORM 990, SCHEDULE R, PART V, LINE 2(4), COLUMN D: CASH TRANSFERRED FROM DDIA TO DELTA DENTAL OF IOWA FOUNDATION METHOD OF DETERMINING AMOUNT INVOLVED - FORM 990, SCHEDULE R, PART V, LINE 2(5), COLUMN D: CAPITAL CONTRIBUTION TO SUBSIDIARY (VERATRUS BENEFIT SOLUTIONS, INC.) METHOD OF DETERMINING AMOUNT INVOLVED - FORM 990, SCHEDULE R, PART V, LINE 2(6), COLUMN D: MANAGEMENT FEES CHARGED TO VERATRUS BENEFIT SOLUTIONS, INC. BASED ON HOURS WORKED METHOD OF DETERMINING AMOUNT INVOLVED - FORM 990, SCHEDULE R, PART V, LINE 2(7), COLUMN D: VISION PREMIUMS BILLED AND COLLECTED BY DDIA ON BEHALF OF VERATRUS BENEFIT SOLUTIONS, INC. CASH WAS TRANSFERRED FROM DDIA TO VERATRUS FOR THESE PREMIUMS.