2011-05-12T15:31:52-05:00 2010-06-30 Eide Bailly LLP 5601 Green Valley Dr Suite 700 Minneapolis MN 554371145 990 2009-07-01 460407148 Avera Workers' Compensation Trust AVER 6053227050 3900 W Avera Dr Sioux Falls SD 57108 John Porter 6053227050 2011-05-09 1 Kim Hunwardsen 9529446166 2011-05-09 2009 2016-02-24 21:20:13Z John Porter 3900 W Avera Dr Sioux Falls SD 57108 4031196 0 X N/A X 1989 SD Provide an economical coverage of workers' compensation claims. 16 12 0 12 0 0 0 3177828 3599235 222080 187259 0 3399908 3786494 0 0 23118 30682 0 0 4296039 4134506 4319157 4165188 -919249 -378694 13548304 15246876 6788879 7829889 6759425 7416987 None 0 0 4049435 3599235 The Avera Workers' Compensation Trust ("Trust") was established to provide an economical coverage of workers' compensation exposure to exempt organizations associated with Avera Health of Sioux Falls in furtherance of their promotion of health care. Stop loss type insurance coverage is purchased by the trust. The participants are required to contribute to the reserves of the trust in accordance with the independent actuarial's valuation. The valuation is made annually to determine the funding level necessary to provide reserves for workers' compensation claims and is reviewed by the Trust's Employer's Advisor. 4049435 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 34 0 1 0 0 0 0 0 0 0 0 0 0 0 16 12 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X Jim Breckenridge 6053224700 3900 W Avera Dr Sioux Falls SD 57108 Rodney W Fouberg 1.00 X X 0 0 0 Sister Lucille Welbig 1.00 X X 0 0 0 John Porter 1.00 X X 0 1015449 43466 Sister Aidan Bourke 1.00 X 0 0 0 Mark Buche 1.00 X 0 0 0 Sister Kathleen Crowley 1.00 X 0 0 0 Sister Mary Jaeger 1.00 X 0 0 0 Daniel P Murphy 1.00 X 0 0 0 Sister Debra Kolecka 1.00 X 0 0 0 Dr James Reynolds 1.00 X 0 0 0 Kevin Conlin 1.00 X 0 0 0 Dr Herbert A Saloum 1.00 X 0 6461 0 Dr Stephan Schroeder 1.00 X 0 165955 18350 Bob Sutton 1.00 X 0 0 0 Sister Mary M Thomas 1.00 X 0 119907 403 Mark Schalanta 1.00 X 0 0 0 US Bank 5.00 X 30682 0 0 30682 1307772 62219 0 0 1 0 Avera Health 3900 W Avera Drive Sioux Falls SD 57108 Shared Services 650000 1 Assessments 524298 3599235 3599235 3599235 431961 431961 244702 -244702 -244702 -244702 3786494 3599235 0 187259 30682 30682 640000 640000 9000 9000 10900 10900 1789 1789 155 155 Insurance Claims 3163653 3163653 Reinsurance Fees 225348 225348 State Fees - SD and IA 75916 75916 Claims Processing Fee 7745 7745 4165188 4049435 115753 0 1251165 1671334 64006 43779 155 12218698 13518004 14280 13759 13548304 15246876 69206 55580 6719673 7774309 6788879 7829889 X 6759425 7416987 6759425 7416987 13548304 15246876 X 0 1 0 X 0 X X X 0 0 0 Avera McKennan 460224743 3 0 0 1 1254012 Avera St Luke's 460224598 3 0 0 1 357593 Sacred Heart Health Services 460225483 3 0 0 1 107366 Avera Queen of Peace 460224604 3 0 0 1 65350 St Benedict Health Center 460226738 3 0 0 1 19363 Avera Holy Family 420680370 3 0 0 1 166132 Presentation College 460280847 2 0 0 1 37971 Sisters of the Presentation of the Blessed Virgin Mary 460253283 1 0 0 1 17348 Avera Health 460422673 9 0 0 1 83879 9 2109014 0 Estimated Claims Payable 7774309 7774309 3786494 4165188 -378694 1036256 1036256 657562 4822750 1036256 1036256 3786494 0 3786494 4165188 0 4165188 0 4165188 Part X: Description of Uncertain Tax Positions Under FIN 48: Avera Workers' Compensation Trust is organized as a nonprofit corporation as described in Section 501(c)(3) of the Internal Revenue Code and is exempt from federal income taxes on related income pursuant to Section 501(a) of the Code. The Organization has implemented Financial Interpretation No. 48, Accounting for Uncertainty in Income Taxes, (FIN No. 48) subsequently codified within FASB ASC 740, Income Taxes. The Organization undergoes an annual analysis of its various tax positions, assessing the likelihood of those positions being upheld upon examination with relevant tax authorities, as defined by the standard. As of June 30, 2010 and 2009 there were no liabilities recorded as a result of this guidance. 0 0 0 0 0 0 0 0 0 John Porter 0 999189 0 0 0 16260 0 28687 0 16459 0 1060595 0 0 Dr Stephan Schroeder 0 163891 0 0 0 2064 0 2742 0 15607 0 184304 0 0 Supplemental Information Part III Schedule J Part I Line 3: John Porter, President and CEO of Avera Health (related organization), is compensated by Avera Health for his services provided to the related organization. The related organization uses methods identified in question 3 to determine compensation. Schedule J Part II - Compensation from Avera McKennan The compensation of the board member is paid by Avera Health. None of the gross wages and benefits are related to his position on the governing body of Avera Workers' Compensation Trust. Form 990, Part VI, Section A, line 3 Avera Health Office of General Counsel serves as the Administrator of the Trust. The Administrator delegates administrative responsibilities to a trust administrator who acts under the direction of the Avera Health General Counsel. The Trust Administrator is an employee of Avera Health, a related organization. Form 990, Part VI, Section B, line 11 The Form 990 is reviewed by the CEO and CFO of Avera Health. The return is provided to the board prior to filing. Form 990, Part VI, Section B, line 12c The Conflict of Interest Policy covers Board members, officers, and key employees. At each board meeting, a request is made for all Board members to disclose any potential conflict of interest pertaining to any item listed on the agenda or pertaining to any potential item that could be discussed during the course of the meeting. The Declaration of Conflict of Interest is recorded in the meeting minutes. The Board makes a determination of whether there is a conflict of interest and if so, implements the procedure for evaluating the issue or transaction involved. The board member or officer with the conflict must refrain from voting. A statement of conflict of interest disclosure is made on an annual basis by officers and directors. The information is maintained in a database and a report is provided to the Board. Part VI, Section B, Line 15: Compensation is determined by Avera Health. The CEO is compensated by Avera Health System. Annually the Compensation Committee of Avera Health, which is comprised of six (6) System Members appointed by the Religious Orders, meets with an independent consultant regarding fair market value of officers and key employees. The Compensation Committee approves all salaries based on comparable data and documents the basis for their decision in meeting minutes. The trustee fee is negotiated by the Board. Form 990, Part VI, Section C, line 19 The organization does not make its governing documents, conflict of interest policy or financial statements available to the public. Form 990 Part XI, Line 2c The independent auditors are selected and approved by the Avera Health Audit Committee and the independent actuary is selected by Avera Health Management. Schedule A, Part I, Line 11f(iv) Organizations as identified in Trust Agreement Avera Workers Compensation Trust was organized by those facilities of Avera Health or its sponsoring religious orders which are identified in the trust document exhibit. The Trust serves as a repository for the employer's funds to meet its obligations to provide workers' compensation benefits to the employer's employees. No organizations are specifically named in the trust document. Instead, the trust agreement defines employer as 'those healthcare facilities and other institutions which are owned or which membership or control of its Board of Directors is controlled by Avera Health'. The facilities and institutions which comprise the employer are identified in Exhibit A to the trust agreement. There is evidence of a historic and continuing relationship with the supported organizations. The amount of support provided on Schedule A, Part IV is related to claims paid on behalf of the employer. Form 990 Part VII Line 1A Column B Average hours devoted to related organizations John Porter devotes an average of 40 hours per week to Avera Health. Dr. Stephen Schroeder and Sister Mary M. Thomas serve Avera McKennan 40 hours per week. All other board members serve Avera Health 5 hours per week. Avera Health 3900 W Avera Drive Suite 300 Sioux Falls SD 57108 460422673 Promotion of Health SD 501(c)(3) 9 N/A Presentation College 1500 North Main Street Aberdeen SD 57401 460280847 College SD 501(c)(3) 2 N/A Avera McKennan 1325 S Cliff Avenue PO Box 5045 Sioux Falls SD 57117 460224743 Healthcare Services SD 501(c)(3) 3 N/A Avera Queen of Peace Fifth and Foster Mitchell SD 57301 460224604 Healthcare Services SD 501(c)(3) 3 N/A Sisters of the Presentation of the Blessed Virgin Mary of Aberdeen SD 15th Avenue and 2nd Street NW Aberdeen SD 57401 460253283 Monastery SD 501(c)(3) 1 N/A Avera St Luke's 305 South State Street Aberdeen SD 57401 460224598 Healthcare Services SD 501(c)(3) 3 N/A St Benedict Hospital Inc 401 West Glynn Drive Parkston SD 57366 460226738 Healthcare Services SD 501(c)(3) 3 N/A Sacred Heart Health Services 501 Summit Street Yankton SD 57078 460225483 Healthcare Services SD 501(c)(3) 3 N/A Avera Holy Family 826 North 8th Street Estherville IA 51334 420680370 Healthcare Services IA 501(c)(3) 3 N/A Sacred Heart Rural Health Clinics Inc 501 Summit Street Yankton SD 57078 460423930 Clinic Services SD 501(c)(3) 3 N/A Health Management Services 501 Summit Yankton SD 57078 460399291 Adult Daycare and Homemaking Services SD 501(c)(3) 9 N/A Avera Education and Staffing Solutions 1000 W 4th ST Suite 9 Yankton SD 57078 460337013 Healthcare Education SD 501(c)(3) 9 N/A Benedictine Health Foundation 1017 West Fifth Street Suite 14 Yankton SD 57078 460370373 Support for Organizations Providing Healthcare Services SD 501(c)(3) 11b N/A St Benedict Health Center Foundation West Glynn Drive PO Box B Parkston SD 57366 460458725 Support Health Related Services SD 501(c)(3) 11a N/A Avera Holy Family Foundation 826 North 8th Street Estherville IA 51334 421317452 Support of Holy Family Hospital an Home Health Agency IA 501(c)(3) 9 N/A Avera St Anthony's Hospital 300 N 2nd Street ONeill NE 687631569 470463911 Healthcare Services NE 501(c)(3) 3 N/A Avera Marshall 300 S Bruce St Marshall MN 56258 410919153 Healthcare Services MN 501(c)(3) 3 N/A Avera Marshall Foundation 300 S Bruce St Marshall MN 56258 411784801 Fundraising MN 501(c)(3) 7 N/A Avera Home Medical Equipment LLC 1325 S Cliff Avenue PO Box 5045 Sioux Falls SD 57117 460488198 Medical Services - Home Medical Equipment SD N/A Midwest Regional Imaging Services LLC 1325 S Cliff Avenue PO Box 5045 Sioux Falls SD 57117 470874983 Health Care - Medical Imaging SD N/A Mersco Medical of Pierre LLC 329 E Dakota Pierre SD 57501 460444002 Medical Services - Home Medical Equipment SD N/A Avera Home Medical Equipment of Floyd Valley Hospital LLC 714 Lincoln ST NE Lemars IA 51031 820582350 Medical Services - Home Medical Equipment IA N/A Avera Home Medical Equipment of Estherville LLC PO Box 5045 Sioux Falls SD 57117 201686097 Medical Services - Home Medical Equipment IA N/A Avera Home Medical Equipment of Sioux Center LLC 38 19th St SW Sioux Center IA 51250 753203100 Medical Services - Home Medical Equipment IA N/A Avera Home Medical Equipment of Marshall LLC 1104 East College Drive Marshall MN 56258 205271924 Medical Services - Home Medical Equipment MN N/A Avera Home Medical Equipment of Spencer Hospital LLC 2400 S Minnesota Av 102 Sioux Falls SD 57117 800619999 Medical Services - Home Medical Equipment SD N/A Q&M Properties LLC 525 North Foster Mitchell SD 57301 731652049 Medical Clinic Building SD N/A Surgical Associates Endoscopy Clinic LLC 310 S Pennsylvania Street Aberdeen SD 57401 460461429 Surgical Associates SD N/A Marshall Medical Services LLC 300 S Bruce St Marshall MN 56258 208874448 Medical Services MN N/A Avera Pace Inc 3900 West Avera Drive Sioux Falls SD 57108 460341869 Healthcare Services SD N/A C Accounts Management Inc 5132 S Cliff Avenue Suite 101 Sioux Falls SD 57108 460373021 Collection Agency SD N/A C Avera Health Plans Inc 3816 S Elmwood Avenue Suite 101 Sioux Falls SD 57108 460451539 Health Financing and Health Plan Admin SD N/A C Avera Property Insurance Inc 610 W 23rd Street Ste 1 PO Box 38 Yankton SD 57078 460463155 Insurance SD N/A C Northern Dakota Health Company 305 S State Street Yankton SD 57401 460385179 Clinics SD N/A C Valley Health Services 501 Summit Street Yankton SD 57078 460357149 Medical Equipment SD N/A C 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 0