2011-11-14T16:34:31-06:00 2010-12-31 ERNST & YOUNG US LLP 111 MONUMENT CIRCLE SUITE 2600 INDIANAPOLIS IN 46204 990 2010-01-01 208530788 Hamden Assurance Risk Retention Group Inc HAMD 6036505668 30 Main Street Suite 330 Burlington VT 05401 Daniel P Jantzen 2011-11-14 3176817000 2010 2016-02-24 21:20:13Z DANIEL P JANTZEN One Medical Center Drive Lebanon NH 03756 4383034 false X N/A X 2007 VT See Attachment 1 6 1 0 0 0 0 0 0 405325 405846 130343 66005 0 0 535668 471851 0 0 0 0 0 0 0 0 0 389098 364974 389098 364974 146570 106877 73050514 78067960 71870642 76740806 1179872 1327154 TO BENEFIT, TO PERFORM THE FUNCTIONS OF, AND TO CARRY OUT THE PURPOSES OF THE CHARITABLE CLASS OF BENEFICIARIES, THROUGH THE PROVISION OF SELF-INSURANCE COVERAGE AND OTHER SERVICES THAT RISK RETENTION GROUPS ARE PERMITTED TO PROVIDE UNDER THE APPLICABLE FEDERAL AND STATE LAW; TO ACQUIRE, ESTABLISH, RETAIN AND MAINTAIN A FUND OR FUNDS TO BE HELD, INVESTED AND USED EXCLUSIVELY FOR THE FOREGOING PURPOSES. false false 295184 405846 Hamden Assurance Risk Retention Group, Inc. (Hamden) was incorporated on February 28, 2007, under the laws of the State of Vermont by its Class A members: Dartmouth-Hitchcock Medical Center, Dartmouth-Hitchcock Clinic, Mary Hitchcock Memorial Hospital and the Trustees of Dartmouth College. Commencing operations on October 1, 2007, Hamden writes medical professional and general liability coverage for its members (insureds) which are also the owners. Insurance coverage is provided though a primary and an excess policy. 295184 true false false false false false false false false false false false true true false true false false false true false false false false false false false false true false false false false false false false false false false false false false true true false false false true 0 0 0 false false false false false false false false false false false X 6 1 false false false false true true true true true false false true true true true false false false X DANIEL P JANTZEN 6036505668 ONE MEDICAL CENTER Lebanon NH 03756 X JOHN C COLLINS 1.0 X X 0 376380 55295 RICHARD H SHOWALTER JR 1.0 X X 0 246600 15077 ADAM M KELLER 1.0 X 0 443092 44022 Anne Page 1.0 X 0 219544 41930 Randall Wachsmann 1.0 X X 0 0 0 Daniel P Jantzen 1.0 X X 0 528264 32570 Peter A Johnson 1.0 X X 0 421481 30493 0 2235361 219387 0 false true false 0 0 CEDING COMMISSIONS 524298 405846 405846 405846 39929 39929 0 0 3937259 3911183 26076 26076 26076 0 0 0 0 471851 405846 66005 0 0 0 0 0 0 0 0 0 0 68425 47898 20527 8518 8518 36000 36000 0 0 4280 4280 0 0 465 465 0 0 0 0 0 0 0 0 0 0 ACTUARIAL FEES 5000 5000 PREMIUM TAX EXPENSE 203451 203451 STATE FEES AND REGISTRATIONS 1130 1130 DUES AND ASSESSMENTS 12299 12299 LINE OF CREDIT FEES 25406 25406 364974 295184 69790 0 656570 459286 1677612 3144553 362923 309154 1847451 2294757 68505958 71860210 73050514 78067960 227643 423198 306000 299537 71336999 76018071 71870642 76740806 X 1050000 1050000 129872 277154 1179872 1327154 73050514 78067960 X 106877 40405 X false true true X false X X X X false false false DARTMOUTH-HITCHCOCK CLINIC 222519596 0 true 256212 MARY HITCHCOCK MEMORIAL HOSPITAL 020222140 0 true 94163 TRUSTEES OF DARTMOUTH COLLEGE 020222111 0 true 5475 DARTMOUTH-HITCHCOCK MEDICAL CENTER 222715483 0 true 9124 4 364974 The Organization provides Medical, Professional, and General Liability Coverage to its member (supported) organizations. In addition, the Organization pays expenses on the behalf of its supporting organizations as part of its ordinary business activties. DEPOSIT ASSET 70854292 LETTER OF CREDIT 1000000 ACCRUED INTEREST 5918 71860210 0 DEPOSIT LIABILITY 72702332 PREMIUM TAXES PAYABLE 171186 DUE TO MEMBERS AND AFFILIATES 3144553 76018071 471851 364974 106877 40405 40405 147282 507511 40405 40405 467106 4745 4745 471851 360229 360229 4745 4745 364974 Schedule D, Part XII Investment expenses reclassed as netted with revenue in the audited financial statements - $4,745 Schedule D, Part XIII Investment expenses reclassed as netted with revenue in the audited financial statements - $4,745. ASC 740 (FIN 48) Footnote Schedule D Part X No ASC 740 (FIN 48) footnote was included in the audited financial statements as there were no material uncertain tax positions at or since adoption. Central America and the Caribbean Program Services Insurance 9133355 9133355 9133355 false false false false false false false true false false false false false false false JOHN C COLLINS 0 104956 0 116408 155016 0 31410 0 23885 0 431675 0 0 RICHARD H SHOWALTER JR 0 179529 0 0 67071 0 0 0 15077 0 261677 0 0 ADAM M KELLER 0 396393 0 0 46699 0 24500 0 19522 0 487114 0 37450 Anne Page 0 217708 0 0 1836 34661 7269 0 261474 0 Daniel P Jantzen 0 469627 0 58637 12250 20320 0 560834 0 0 Peter A Johnson 0 388659 0 0 32822 0 8820 0 21673 0 451974 0 0 Dartmouth-Hitchcock Defined Contribution Supplemental Retirement Plan Schedule J, Part I, Line 4b Peter Johnson received $32,822 from a supplemental non-qualified retirement plan. John Collins received $26,745 from a supplemental non-qualified retirement plan. Daniel Jantzen received $58,223 from a supplemental non-qualified retirement plan. Anne Page received $14 from a supplemental non-qualified retirement plan. Richard Showalter received $23,700 from a supplemental non-qualified retirement plan. Terms and Conditions: An eligible employee is a participant in the Dartmouth-Hitchcock Retirement Plan and/or any prior pension arrangements sponsored by Dartmouth-Hitchcock (including two qualified defined benefit plans) who would be entitled to additional contributions or benefit accruals under the terms of the plans for the plan year, but are limited by IRC Section 401(A) and/or 415. For eligible employees, the employer will pay the eligible employee an amount determined by the employer each year to offset the amount of the reduction in the benefit accrual or contributions as a result of limitations imposed by IRC sections 401(A)(17) and/or 415. Description of Organization's Delegation of Management Control Form 990, Part VI, Line 3 The Organization has a management agreement with Chartis Insurance Management Services to provide day-to-day accounting, and administrative services (such as legal and insurance registrations). In addition, the Organization has a claims service agreement with Atlantic Risk Management (ARM) to provide third-party claims administration services. ARM is a division of the Dartmouth-Hitchcock Clinic. However, the board retains all voting rights and decision making over the Organization. Description of Classes of Members or Stockholders Form 990, Part VI, Line 6 There are two classes of members: Class A Members and Class B Members. The initial Class A Members shall be Dartmouth-Hitchcock, Dartmouth-Hitchcock Clinic, Mary Hitchcock Memorial Hospital, and the Trustees of Dartmouth College. Class B Members shall be entities affiliated with or related to the Class A Members. affiliated with or related to the Class A Members. Description of Classes of Persons and the Nature of Their Rights Form 990, Part VI, Line 7a Each class A Member shall have full voting rights. The number of votes Each Class A Member Shall be entitled to cast on each matter submitted to a vote of the members shall be based on a ratio that one class A member's risk bears to risks all Class A members of the corporation as set forth in the Coporation's Bylaws, Predicated on either the class A member's first year premiums or deposits. Class B members shall, voting as a separate class, have the right to elect one Class B Director of the Corporation. Class B Members shall NOT have the right to vote on any other matters submitted to a vote of the Members, except as otherwise provided under Vermont law. Each class B Member shall have one vote for each matter on which the class B members are entitled to vote. Descr Classes of Persons, Decisions Requiring Appr & Type of Voting Rights Form 990, Part VI, Line 7b The affairs of the Organization shall be managed by a Board of Directors consisting of at least three and no more than seven members of Dartmouth-Hitchcock Clinic, Mary Hitchcock Memorial Hospital, and the Trustees of Dartmouth College. The Class B Members shall, voting as a separate class, have the right to elect one Class B Director of the Organization. All additional members of the Board of Directors, if any shall be appointed by the Hospital, and the Trustees of Dartmouth College. Governance Over Approval and Filling of 990 Form 990, Part VI, Line 11b An ad hoc committee including at least, but not limited to, the president and vice president review the form before its filing and report to the board at their annual meeting. Conflict of Interest Policy Enforcement Form 990, Part VI, Line 12c The entity has a conflict of interest policy which requires Directors and Officers to disclose potential conflicts of interest of themselves and family members. A conflict of interest statement is required to be completed of each Director or Officer on an annual basis. The solicitation and collection of interest statements is organized by legal counsel who submit to the Board of Directors any statements that disclose a potential conflict of interest. Any conflicts disclosed or otherwise perceived are required to be addressed by the Board of Directors; whereupon any action including, but not limited to, restriction would be determined. If the board or committee has reasonable cause to believe that an interested person has failed to disclose actual or possible conflicts of interest, it shall inform such person on the basis for such belief and afford him/her an opportunity to explain the alleged failure to disclose. If, after hearing the response of the interested person and making such further investigation as may be warranted in the circumstances, the board or committee determines that such person has in fact failed to disclose an actual or possible conflict of interest, it shall take appropriate disciplinary and corrective action. Policies Form 990, Part VI, Line 13 and 14 The organization is currently in the process of reviewing and approving a formal Whistleblower and Record Retention Policy at the board level. Avail of Gov Docs, Conflict of Interest Policy, & Fin Stmts to Gen Public Form 990, Part VI, Line 19 The Organization makes its governing documents, conflict of interest policy, and financial statements available to the public upon request. Other Changes in Net Assets or Fund Balances Form 990, Part XI, Line 5 Other Changes in net assets or fund balances: $40,405 unrealized gain/losses HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:JOHN C COLLINS TITLE:CHAIRMAN HOURS:40 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:RICHARD H SHOWALTER JR TITLE:SECRETARY/TREAS.UNTIL(4/30/10) HOURS:60 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:ADAM M KELLER TITLE:DIRECTOR HOURS:40 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Anne Page TITLE:Director HOURS:40 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Daniel P. Jantzen TITLE:Secrerary/Treas.(Eff 4/30/10) HOURS:60 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Peter A. Johnson TITLE:President (Eff 4/30/10) HOURS:60 Dartmouth-Hitchcock Clinic One Medical Center Drive Lebanon NH 03756 222519596 Healthcare NH 501(C)(3) 9 D-H Health Mary Hitchcock Memorial Hospital One Medical Center Drive Lebanon NH 03756 020222140 Hospital NH 501(C)(3) 3 D-H Health Dartmouth College 37 Dewey Field Road Hanover NH 03755 222527266 Higher Educ. NH 501(C)(3) 2 NA Dartmouth-Hitchcock Medical Center One Medical Center Drive Lebanon NH 03756 222715483 Support Org. NH 501(C)(3) 11 Type I NA Dartmouth-Hitchcock Health One Medical Center Drive Lebanon NH 03756 264812335 Healthcare NH 501(C)(3) 7 NA false false false false false false false false false false true false false false false false false true