2022-11-14T13:17:28-06:00 2021-12-31 381357951 PLANTE & MORANPLLC 1111 MICHIGAN AVE PO BOX 2500 EAST LANSING MI 488262500 990 2021-01-01 381791480 DELTA DENTAL PLAN OF MICHIGAN INC DELT 5173496000 4100 OKEMOS ROAD OKEMOS MI 48864 AMY BASEL CFO 5173496000 2022-11-10 1 AMY BASEL 999009999 DAVID LOWENTHAL CPA P00378651 5173326200 2022-11-10 3 AAL1 IAL1 2021 2022-09-23 18:48:47Z GORAN JURKOVIC 4100 OKEMOS ROAD OKEMOS MI 48864 1175896397 0 X WWW.DELTADENTALMI.COM X 1957 MI DELTA DENTAL OF MICHIGAN'S MISSION IS TO ADVANCE AND PROMOTE THE IMPROVEMENT OF ORAL HEALTH THROUGH DENTAL SERVICES PROVIDED UNDER CONTRACTS WITH INDEPENDENT PROFESSIONAL SERVICE PROVIDERS, SUPPORT FOR RESEARCH AND EDUCATION, AND COMMUNITY OUTREACH DIRECTED TOWARD SECURING ACCESS TO QUALITY DENTAL CARE FOR ALL. 15 12 1197 0 41888545 0 0 0 884194894 963288759 29338836 28878623 138284 22660 913672014 992190042 15810717 7629688 0 0 129019124 153737523 0 0 0 753463943 813500894 898293784 974868105 15378230 17321937 824076353 855270608 182285417 168458126 641790936 686812482 X SEE SCHEDULE ODELTA DENTAL OF MICHIGAN'S MISSION IS TO ADVANCE AND PROMOTE THE IMPROVEMENT OF ORAL HEALTH THROUGH DENTAL SERVICES PROVIDED UNDER CONTRACTS WITH INDEPENDENT PROFESSIONAL SERVICE PROVIDERS, SUPPORT FOR RESEARCH AND EDUCATION, AND COMMUNITY OUTREACH DIRECTED TOWARD SECURING ACCESS TO QUALITY DENTAL CARE FOR ALL. DELTA DENTAL OF MICHIGAN IS GOVERNED BY A BOARD OF DIRECTORS CONTROLLED BY INDEPENDENT MEMBERS OF THE COMMUNITY AND IT OFFERS ENROLLMENT IN ORAL HEALTH PLANS TO A BROAD BASE OF THE COMMUNITY THROUGH A VARIETY OF PAYMENT MODELS. 0 0 853641751 7629688 921400214 PROMOTING DENTAL CAREDELTA DENTAL PLAN OF MICHIGAN, INC. IS A LEADING PREPAID DENTAL BENEFITS PROVIDER IN THE MIDWEST. THE PURPOSE OF THE ORGANIZATION IS TO ADVANCE AND PROMOTE THE IMPROVEMENT OF ORAL HEALTH. THIS IS DONE BY OFFERING INNOVATIVE, COST-EFFECTIVE PRODUCTS THAT MEET THE NEEDS OF CUSTOMERS. THIS WAS DEMONSTRATED IN 2021 BY PAYING OUT OVER $536 MILLION FOR DENTAL CARE, BY PROVIDING DENTAL BENEFITS FOR THE PUBLIC AND ADVANCING THE SCIENCE OF DENTISTRY. IN ADDITION, OVER 10.4 MILLION CLAIMS WERE PROCESSED FOR OVER 5.7 MILLION MEMBERS.SEE CONTINUATION ON SCHEDULE OCOST SAVING STRATEGIESDELTA DENTAL BENEFIT PLANS ARE COMMITTED TO SAVING GROUPS AND MEMBERS MONEY. THE DELTA DIFFERENCE IS AN INTEGRATION OF ACTIVITIES; SUCH AS COST MANAGEMENT POLICIES, FEE REDUCTION AGREEMENTS WITH DENTISTS, AND AN ANTI-FRAUD HOTLINE, PUT TO WORK ENSURING QUALITY, COST-EFFECTIVE DENTAL BENEFIT DELIVERY. COMMITMENT TO THE COMMUNITYDELTA DENTAL PLAN OF MICHIGAN, INC. BELIEVES ADVANCES IN DENTAL RESEARCH AND ENHANCED EDUCATIONAL OPPORTUNITIES FOR DENTISTS GO A LONG WAY TOWARD IMPROVING ORAL HEALTH. THE COMPANY IS A KEY PLAYER IN GROUNDBREAKING RESEARCH ON TRENDS IN ORAL HEALTH IN THE INSURED POPULATION. THE DELTA DENTAL FUND, THE COMPANY'S PHILANTHROPIC AFFILIATE, ENCOURAGES ADVANCES IN DENTISTRY AND SUPPORTS DENTAL EDUCATION AND RESEARCH. SINCE IT WAS FORMED IN 1980, THE DELTA DENTAL FUND HAS GRANTED OVER $47 MILLION TOWARD THE ADVANCEMENT OF DENTAL SCIENCE AND IMPROVEMENT OF THE ORAL HEALTH OF THE PUBLIC. DELTA DENTAL FUND REGULARLY PROVIDES FUNDING FOR PROGRAMS THAT HELP AT-RISK POPULATIONS AND INDIVIDUALS WITH SPECIAL NEEDS OBTAIN DENTAL TREATMENT, SCHOLARSHIP AND LEADERSHIP AWARDS TO DENTAL STUDENTS, GRANTS TO PURCHASE LEARNING TOOLS AND OTHER DENTAL SCHOOL PROGRAMS, CONTINUING EDUCATION PROGRAMS FOR THE DENTAL PROFESSION, AND EDUCATIONAL MATERIALS ON THE IMPORTANCE OF ORAL HEALTH AND HAZARDS TO ORAL HEALTH.IN 2021, DELTA DENTAL FUND PROVIDED GRANTS TOTALING NEARLY $4 MILLION FOR DENTAL AND COMMUNITY RELATIONS PROJECTS. THIS FUNDING HAS IMPROVED ORAL AND OVERALL HEALTH, ADDED TO WHAT WE KNOW ABOUT DENTAL SCIENCE, HELPED STUDENTS ACHIEVE THEIR GOALS AND IMPROVED THE WELL-BEING OF THOUSANDS OF CHILDREN AND ADULTS IN MICHIGAN, INDIANA, OHIO AND NORTH CAROLINA.DELTA DENTAL PLAN OF MICHIGAN IS ALSO COMMITTED TO BUILDING HEALTHY, SMART, VIBRANT COMMUNITIES. DELTA DENTAL HAS ALWAYS BEEN KEENLY AWARE OF ITS CIVIC AND SOCIAL RESPONSIBILITY. DELTA DENTAL PLANS ARE PROUD TO SHARE, THROUGH DIRECT FINANCIAL CONTRIBUTIONS, WITH HUNDREDS OF COMMUNITY AGENCIES AND GROUPS. IN ADDITION, EMPLOYEES LOG COUNTLESS HOURS OF THEIR OWN TIME AS VOLUNTEERS. COMMUNITY SUPPORT GENERALLY FALLS UNDER THE BROAD CATEGORIES THAT PROVIDE SUPPORT TO AGENCIES AND INSTITUTIONS SERVING CHILDREN, SENIORS, LOW-INCOME INDIVIDUALS, MINORITIES, AND DISABLED AND AT-RISK INDIVIDUALS, TO ORGANIZATIONS THAT PROMOTE EDUCATION, ARTS AND RECREATION AND COMMUNITY DEVELOPMENT, AND TO CHARITABLE PROJECTS OR PROGRAMS RECOMMENDED BY EMPLOYEES, CUSTOMERS, PARTICIPATING DENTISTS AND OTHER KEY GROUPS. WE CONTINUED OUR ROLE AS STRONG ADVOCATES FOR SOUND ORAL HEALTH POLICY AT THE STATE AND FEDERAL LEVELS. THROUGH A PUBLIC-PRIVATE PARTNERSHIP WITH THE MICHIGAN DEPARTMENT OF COMMUNITY HEALTH, DELTA DENTAL PARTICIPATES IN THE HEALTHY KIDS DENTAL (HKD) PROGRAM. HEALTHY KIDS DENTAL IS A DENTAL BENEFITS PROGRAM FOR MEDICAID BENEFICIARIES UNDER AGE 21. IT IS AVAILABLE IN ALL OF MICHIGAN'S 83 COUNTIES AND COVERS BASIC DENTAL HEALTH BENEFITS SUCH AS X-RAYS, CLEANINGS, CAVITY FILLINGS, ROOT CANALS, TOOTH EXTRACTIONS AND DENTURES. NEARLY 1,000,000 MICHIGAN CHILDREN ARE SERVED BY THIS PROGRAM. UNEQUALED ACCESS TO DENTISTSFOR FIVE DECADES, DELTA DENTAL HAS HELPED PROMOTE ORAL HEALTH BY DESIGNING AND ADMINISTERING INNOVATIVE, COST-EFFECTIVE DENTAL BENEFIT PROGRAMS. EXPERTS AT PLAN DESIGN, DELTA DENTAL HAS CREATED DENTAL BENEFIT PROGRAMS THAT MEET CUSTOMER COST-OBJECTIVES WHILE HELPING TO IMPROVE AND MAINTAIN ORAL HEALTH.OUR LONG STANDING RELATIONSHIPS WITH PROVIDERS IN THE COMMUNITIES WE SERVE ALLOWS US TO MAINTAIN LARGE NETWORKS, ALLOWING BROAD ACCESS FOR MEMBERS AND COST-EFFECTIVE CARE. DELTA DENTAL'S GROUP MEMBERS ARE AFFORDED ADDED PROTECTION BECAUSE THEY GUARANTEE THAT PARTICIPATING DENTISTS WILL ACCEPT THEIR PAYMENT FOR COVERED SERVICES AND NO CHARGE, OTHER THAN CO-PAYMENTS AND DEDUCTIBLES ARE BILLED BACK TO THE MEMBER. THIS LOWERS CLAIM COSTS FOR CUSTOMERS AND REDUCES OUT-OF-POCKET COSTS FOR SUBSCRIBERS.WITH TWO NETWORKS OF FULL-TIME PARTICIPATING DENTISTS IN ONE INTEGRATED CLAIMS SYSTEM, DELTA DENTAL CAN DELIVER TO CUSTOMERS AND GROUP MEMBERS BROAD ACCESS TO CARE. 853641751 0 0 1 0 0 0 0 0 0 1 1 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 1 0 1 62210 0 1 1197 1 1 1 0 0 0 0 0 1 0 X 15 12 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 X AMY BASEL CFO 5173496000 4100 OKEMOS ROAD OKEMOS MI 48864 X GORAN JURKOVIC CPA CEO, PRESIDENT 35.00 15.00 X 6436475 0 2150877 ANTHONY ROBINSON SVP & CHIEF MKT OFFICER 43.00 7.00 X 1720896 0 495456 AMY BASEL SVP, CFO, CRO & TREASURER 35.00 15.00 X 1522877 0 446465 SUE ELLEN JENKINS SVP, CHIEF LEGAL OFF, CAO & SEC. 37.00 13.00 X 1037021 0 297452 TOBY HALL SVP, CHIEF ACTUARY & DATA OFFICER 50.00 0.00 X 756770 0 316882 JEFF BOTKIN SVP, BUSINESS SVS 50.00 0.00 X 731675 0 95834 MARK BAUGHMAN OPERATING CIO 50.00 0.00 X 733786 0 81467 MICHAEL GILMORE FORMER VP, CHIEF INVEST OFFICER 0.00 50.00 X 689026 0 65859 KUSHTRIM SHAQIRI VP GOVERNMENT PROGRAMS 50.00 0.00 X 610420 0 35848 JEFFREY JOHNSTON SVP, CHIEF SCIENCE OFFICER 43.00 7.00 X 461838 0 87946 MIKE BOBAK VP SALES 50.00 0.00 X 403866 0 53942 DANIEL LOVEJOY DIRECTOR, SALES & ACCT MGT 50.00 0.00 X 373939 0 49820 MARGARET TRIMER VP STRATEGIC PARTNERSHIPS 50.00 0.00 X 341956 0 78231 WALTER BUZANOWSKI VP & GENERAL COUNSEL 50.00 0.00 X 357626 0 60368 EARL MAJOR VP HUMAN RESOURCES 50.00 0.00 X 216866 0 53942 CHRISTOPHER T FISHER DIRECTOR 5.00 10.00 X 60000 107004 0 JOSHUA S HOWIE VICE-CHAIRPERSON - THRU 5/21 5.00 5.00 X X 27500 141468 0 SARA M DOLAN VICE-CHAIRPERSON 5.00 5.00 X X 63500 66467 0 JOSEPH C HARRIS DDS DIRECTOR - THRU 5/21 5.00 6.00 X 104116 12415 0 MELISSA STOLICKER DIRECTOR 5.00 5.00 X 60000 50004 0 STEPHEN A EKLUND DIRECTOR 5.00 6.00 X 60000 26996 0 KURT D GALLINGER DIRECTOR 5.00 5.00 X 60000 24996 0 KELLY JUBB SCHEIDERER CHAIRPERSON 5.00 6.00 X X 52500 32000 0 ANN MARIE FLERMOEN DIRECTOR - THRU 5/21 5.00 11.00 X 25000 57750 0 RAYMOND F GIST DDS DIRECTOR 5.00 1.00 X 60000 2000 0 LARRY DEGROAT DIRECTOR 5.00 0.00 X 60000 0 0 PATRICK GILLESPIE DIRECTOR 5.00 0.00 X 60000 0 0 ANDREW KOTARBA DIRECTOR 5.00 0.00 X 60000 0 0 STEVEN M DATER DDS MS DIRECTOR 5.00 0.00 X 40000 0 0 STEVEN M TACK DDS MS DIRECTOR 5.00 0.00 X 40000 0 0 SUNCICA TRAVAN DDS MS DIRECTOR 5.00 0.00 X 40000 0 0 ANTHONY O WILLIAMS JD DIRECTOR 5.00 0.00 X 40000 0 0 DOUGLAS R ANDERSON DIRECTOR - THRU 5/21 5.00 5.00 X 25000 10415 0 CURLES C COLBERT JR DDS DIRECTOR - THRU 9/21 5.00 0.00 X 35000 0 0 BLAKE LIVINGSTON DDS DIRECTOR 5.00 0.00 X 0 0 0 17367653 531515 4370389 289 1 1 0 DEWPOINT 300 WASHINGTON SQUARE SUITE 200 LANSING MI 48933 CONSULTING 19178416 WEST MONROE PARTNERS LLC 222 W ADAMS ST FL 11 CHICAGO IL 60606 CONSULTING 6398474 MAINLINE INFORMATION SYSTEMS 1700 SUMMIT LAKE DR TALAHASSEE FL 32317 CONSULTING 4293266 TEK SYSTEMS 300 WASHINGTON SQUARE SUITE 430 LANSING MI 48933 CONSULTING 3542316 DPM CONSULTING SERVICES 5440 CORPORATE DR STE 125 TROY MI 48098 CONSULTING 3043965 104 DENTAL CARE REVENUE 624100 825996218 825996218 ADMIN REIMBURSEMENT 900099 95403996 95403996 EXTERNAL SERVICES 524292 41888545 41888545 963288759 4600374 4600374 207899004 85600 183658472 47883 24240532 37717 24278249 24278249 MISCELLANEOUS INCOME 900099 22660 22660 22660 992190042 921400214 41888545 28901283 X 7629688 7629688 17279642 11231767 6047875 95887284 57009762 38877522 17214286 9340676 7873610 16336156 9026462 7309694 7020155 4335664 2684491 4112950 3196817 916133 523305 523305 365860 365860 120000 120000 1640171 1640171 714929673 695314620 19615053 4506367 3223939 1282428 14219506 10237477 3982029 21748646 11840912 9907734 4766940 4766940 2703836 2266399 437437 370863 215900 154963 18402613 5058167 13344446 1830167 1830167 FEDERAL & STATE TAX EXP -2546396 -2546396 COMMISSIONS 20295912 20295912 PROCESSING FEES 2366341 2366341 MEMBERSHIP DUES 2245798 353660 1892138 898342 697588 200754 974868105 853641751 121226354 0 58242529 73200984 60459627 61618463 28169115 39578214 244297119 122671083 133099761 121626036 273517808 278724900 224991567 226398759 45595946 54123252 824076353 855270608 82138272 92658909 100147145 75799217 182285417 168458126 X 15744473 15744473 5122500 5122500 620923963 665945509 641790936 686812482 824076353 855270608 X 17321937 6543252 21156357 X 0 1 X 1 0 13500 13500 1 MOVING MACOMB 106 W ALLEGAN STE 200 LANSING MI 48933 833929631 1500 BUSINESS LEADERS FOR MICHIGAN PAC II 600 RENAISSANCE CENTER DETROIT MI 48243 273999229 10000 MICHIGAN ASSOCIATION FOR HEALTH PLANS ADVOCACY PAC 327 SEYMOUR AVE LANSING MI 48933 454092817 1000 ROAD TO MICHIGANS FUTURE PO BOX 12248 LANSING MI 48901 844298056 1000 1 0 0 12803920 12803920 98462514 37468829 60993685 48249007 33661198 14587809 84781678 51541056 33240622 121626036 DDIC STOCK 200217 C INVESTMENT IN RHC 107614629 F INVESTMENT IN THE 4100 GROUP 118583913 F 226398759 ACCRUED INTEREST RECEIVABLE 550354 DUE FROM AFFILIATES 17200023 OTHER ASSETS 34149693 DEFERRED TAX ASSET 2223182 54123252 IBNR - CLAIM ADJUSTMENT RESERVES 17648253 UNEARNED PREMIUMS 23841369 PENSION & POST RETIRE OBLIGATIONS 2442807 DUE TO AFFILIATES 2316077 RISK-SHARING PAYABLES 29550711 75799217 1 AMERICAN CANCER SOCIETY 20450 CIVIC CENTER DR SOUTHFIELD MI 48076 131788491 501(C)(3) 32000 0 CHARITABLE DONATION AUTISM ALLIANCE OF MICHIGAN 30100 TELGRAPH RD BINGHAM FARMS MI 48025 270472137 501(C)(3) 50000 0 CHARITABLE DONATION CHILDRENS HOSPITAL OF MICHIGAN FOUNDATION 3011 W GRAND BLVD DETROIT MI 48202 320087353 501(C)(3) 50000 0 CHARITABLE DONATION COMMUNITIES IN SCHOOLS OF MICHIGAN 721 N CAPITOL STE 1 LANSING MI 48906 453736821 501(C)(3) 200000 0 CHARITABLE DONATION DELTA DENTAL FOUNDATION 4100 OKEMOS RD OKEMOS MI 48864 382337000 501(C)(3) 4000000 0 CHARITABLE DONATION DETROIT RIVERFRONT CONSERVANCY 600 RENAISSANCE CENTER DETROIT MI 48243 300125283 501(C)(3) 1015000 0 CHARITABLE DONATION ELE'S PLACE 1145 WEST OAKLAND LANSING MI 48915 382976751 501(C)(3) 130000 0 CHARITABLE DONATION FORGOTTEN HARVEST 21800 GREENFIELD RD OAK PARK MI 48237 382926476 501(C)(3) 150000 0 CHARITABLE DONATION GREATER LANSING FOODBANK 5303 S CEDAR ST LANSING MI 48911 382424756 501(C)(3) 35000 0 CHARITABLE DONATION IMPRESSION 5 200 MUSEUM DR LANSING MI 48933 237200548 501(C)(3) 40000 0 CHARITABLE DONATION JUNIOR ACHIVEVEMENT OF SOUTHEASTERN MI 577 E LARNED ST DETROIT MI 48226 381348535 501(C)(3) 85000 0 CHARITABLE DONATION JUVENILE DIABETES RESEARCH FOUNDATION 24359 NORTHWESTERN HWY SOUTHFIELD MI 48075 231907729 501(C)(3) 55000 0 CHARITABLE DONATION LANSING PROMISE 330 MARSHALL ST LANSING MI 48912 453363322 501(C)(3) 50000 0 CHARITABLE DONATION MICHIGAN COLLEGE ALLIANCE 26555 EVERGREEN RD STE 1210 SOUTHFIELD MI 48076 381332962 501(C)(3) 10000 0 CHARITABLE DONATION MICHIGAN ECONOMIC DEVELOPMENT FOUNDATION PO BOX 13063 LANSING MI 48901 382527475 501(C)(3) 25000 0 CHARITABLE DONATION MICHIGAN STATE UNIVERSITY 220 TROWBRIDGE RD EAST LANSING MI 48824 386005984 GOVT 500000 0 CHARITABLE DONATION ON DEMAND KARE INC 2500 W BROADWAY LOUISVILLE KY 40211 831468041 501(C)(3) 150000 0 CHARITABLE DONATION PLAYWORKS EDUCATION ENGERGIZED 1423 BROADWAY PMB 161 OAKLAND CA 94120 943251867 501(C)(3) 10000 0 CHARITABLE DONATION ROAD TO MICHIGANS FUTURE PO BOX 12248 LANSING MI 48901 844298056 501(C)(4) 100000 0 CHARITABLE DONATION SAMARITAS 8131 E JEFFERSON AVE DETROIT MI 48214 381360553 501(C)(3) 45000 0 CHARITABLE DONATION SPARROW FOUNDATION PO BOX 30480 LANSING MI 48909 386100687 501(C)(3) 75000 0 CHARITABLE DONATION THE FIRST TEE OF LAKE ERIE LLC PO BOX 351142 TOLEDO OH 43635 465657531 501(C)(3) 73333 0 CHARITABLE DONATION WEEKEND SURVIVAL KITS 319 W GRAND RIVER AVE WILLIAMSTON MI 48895 454444119 501(C)(3) 75000 0 CHARITABLE DONATION HOPE NETWORK FOUNDATION 3375 SOUTH DIVISION 200 GRAND RAPIDS MI 49448 382731395 501(C)(3) 10000 0 CHARITABLE DONATION JUNIOR ACHIEVEMENT OF MICHIGAN GREAT LAKES 600 W ST JOSEPH ST LANSING MI 48933 381557861 501(C)(3) 44500 0 CHARITABLE DONATION THE OHIO STATE UNIVERSITY 305 W 12TH AVE COLUMBUS OH 43210 316025986 GOVT 85995 0 CHARITABLE DONATION AMERICAN INDIA FOUNDATION 216 EAST 45TH ST NEW YORK NY 10017 134159765 501(C)(3) 6110 0 CHARITABLE DONATION AMERICAN RED CROSS 7800 W OUTER DR DETROIT MI 48235 530196605 501(C)(3) 50000 0 CHARITABLE DONATION ARTRPRIZE GRAND RAPIDS 225 MICHIGAN ST NW GRAND RAPIDS MI 49501 264571560 501(C)(3) 250000 0 CHARITABLE DONATION DETROIT PUBLIC SCHOOLS FOUNDATION FISHER BUILDING DETROIT MI 48202 300135450 501(C)(3) 110000 0 CHARITABLE DONATION FREESTORE FOODBANK INC 1141 CENTRAL PARKWAY CINCINNATI OH 45202 337122205 501(C)(3) 10000 0 CHARITABLE DONATION JUNIOR ACHIEVEMENT OF CENTRAL OHIO 68 E 2ND AVENUE COLUMBUS OH 43201 314385042 501(C)(3) 35000 0 CHARITABLE DONATION JUNIOR ACHIEVEMENT OF NW OHIO 1645 INIDAN WOOD CIRCLE MAUMEE OH 43537 344430363 501(C)(3) 25000 0 CHARITABLE DONATION MICHIGAN HUMANE SOCIETY 30300 TELEGRAPH BINGHAM FARMS MI 48025 381358206 501(C)(3) 25000 0 CHARITABLE DONATION MICHIGAN CITIZENS FOR FISCAL RESPONSIBILITY 106 W ALLEGAN STREET NO 200 LANSING MI 48933 271993953 501(C)(4) 6250 0 CHARITABLE DONATION NATIONAL ASSOCIATION OF DENTAL PLANS 12700 PARK CENTRAL DR DALLAS TX 75251 752801959 501(C)(6) 16500 0 CHARITABLE DONATION 33 3 PART I, LINE 2: CONTRIBUTIONS ARE MADE AT MANAGEMENT DISCRETION TO ORGANIZATIONS THAT SUPPORT DELTA DENTAL PLAN OF MICHIGAN'S MISSION. CONTRIBUTIONS MADE TO THE DELTA DENTAL FUND ARE APPROVED BY THE BOARD OF DIRECTORS. IN ORDER FOR FUNDS TO BE DISBURSED, VOUCHER RECORDS MUST PASS THROUGH THE APPROVAL PROCESS, SIMILAR TO ANY OTHER EXPENDITURE MADE BY DELTA DENTAL PLAN OF MICHIGAN. DETROIT RIVERFRONT CONSERVANCY - DELTA DENTAL OF MICHIGAN CONTRIBUTED $1 MILLION TO BUILD A HEALTH THEMED PLAYGROUND ON DETROIT'S WEST RIVERFRONT. COMMUNITIES IN SCHOOLS OF MICHIGAN - THIS CONTRIBUTION HELPED CIS OF MICHIGAN DEVELOP THE WHOLE-CHILD SCREENER AND CHECK-IN PROCESS TO ASSESS THE NUTRITIONAL, DENTAL, EDUCATIONAL, PHYSICAL HEALTH, AND MENTAL HEALTH NEEDS OF CASE-MANAGEMENT STUDENTS. THIS NEW NEEDS ASSESSMENT PROCESS ENSURES SITE COORDINATORS CAN IDENTIFY IMMEDIATE NEEDS OF STUDENTS TO BROKER AND IMPLEMENT SUPPORTS. THIS ENSURES SITE COORDINATORS CAN REFER STUDENTS TO A DENTIST AND HELP INCREASE SCHOOL-BASED DENTAL SUPPORTS. CHILDREN'S HOSPITAL OF MICHIGAN FOUNDATION - THIS WAS A CAPITAL CONTRIBUTION TO THE JAMIE DANIELS FOUNDATION (A FUND WITHIN THE CHILDREN'S FOUNDATION) TO ASSIST WITH THE BUILDING OF A RESIDENTIAL OPIOID RECOVERY FACILITY IN SOUTHEASTERN MICHIGAN. ON DEMAND KARE - FOR KARE MOBILE DENTAL PROGRAM THAT CONTRIBUTES ONE-CHAIR MOBILE DENTAL UNITS TO ENTREPRENEUR DENTIST AND HYGENTIST IN SE MICHIGAN TO BOTH SERVE THE MEDICAID POPULATION PART-TIME AND TO BUILD A THRIVING BUSINESS THE OTHER HALF OF THE TIME. FORGOTTEN HARVEST - DELTA DENTAL OF MICHIGAN CONTRIBUTED $150,000 TO THIS FOOD RESCUE/FOOD BANK PROGRAM OPERATING IN THE DETROIT AREA. THEY PROVIDE LUNCHES FOR CHILDREN PARTICIPATING IN THE DETROIT PUBLIC LIBRARY SUMMER CAMP PROGRAMS AS WELL AS OPERATE SEVERAL FARMERS MARKET STYLE FOOD BANK DISTRIBUTION SITES THROUGHOUT SOUTHEASTERN MICHIGAN. ELE'S PLACE - IN 2021, DELTA DENTAL OF MICHIGAN PROVIDED $130,000 TO ELE'S PLACE TO SUPPORT ELE'S GROUP, THEIR SCHOOL BASED GRIEF COUNSELING PROGRAM. THROUGH THIS PROGRAM, ELE'S PLACE IS ABLE TO REACH CHILDREN WHO MAY NOT OTHERWISE HAVE TRANSPORTATION TO RECEIVE GRIEF COUNSELING SERVICES AT THEIR OFFICES. LANSING PROMISE - DELTA DENTAL PROVIDED $50,000 IN FUNDING TO THE LANSING PROMISE IN 2021. LANSING PROMISE IS A SCHOLARSHIP PROGRAM OFFERING TUITION ASSISTANCE FOR POST-SECONDARY (COLLEGE OR SKILLED TRADE) EDUCATION TO ALL ELIGIBLE HIGH SCHOOL GRADUATES WITHIN THE LANSING SCHOOL DISTRICT BOUNDARIES. THE PROMISE PROVIDES TUITION ASSISTANCE FOR UP TO 65 CREDITS AT LANSING COMMUNITY COLLEGE OR THE EQUIVALENT DOLLAR AMOUNT TOWARD TUITION AND FEES AT MICHIGAN STATE UNIVERSITY OR OLIVET COLLEGE. SPARROW FOUNDATION - OUR DONATION WAS USED TO SPONSOR A VARIETY OF FUNDRAISING EVENTS ALL FOCUSED ON SUPPORTING THE SPARROW FOUNDATION WHICH PLAYS A CRITICAL ROLE IN THE HEALTH SYSTEM LIFE CYCLE BY COLLECTING RESOURCES, BOOSTING COMMUNITY AWARENESS AND IMPROVING THE OVERALL HEALTH OF PEOPLE IN MID-MICHIGAN. ART PRIZE GRAND RAPIDS - THIS SPONSORSHIP SUPPORTED A NEW EVENT APP THAT ALLOWED PARTICIPANTS TO VOTE ON INDIVIDUAL ART PIECES, WHILE ALSO ACCESSING WAY FINDING AND OTHER INFORMATION DURING THE ARTPRIZE EVENT. ARTPRIZE IS AN INDEPENDENT, INTERNATIONAL ART COMPETITION IN GRAND RAPIDS THAT CELEBRATES ARTISTS WORKING IN ALL MEDIUMS FROM ANYWHERE IN THE WORLD. DETROIT PUBLIC SCHOOL FOUNDATION - THIS DONATION WAS MADE TO IMPLEMENT A COMMUNITY HEALTH HUB PROGRAM THAT CONNECTS STUDENTS AND FAMILIES TO COMPREHENSIVE SERVICES AND IMPROVES CONNECTIONS BETWEEN SCHOOLS AND NEIGHBORHOODS. SPECIFICALLY, OUR FUNDING WAS USED TO HIRE A SCHOOL SITE COORDINATOR ASSIGNED TO THE FAMILY RESOURCE DISTRIBUTION CENTER LOCATED AT THE ADULT EDUCATION CENTER WEST. X X X 1 1 X X X X X 0 1 0 0 0 0 0 1 0 GORAN JURKOVIC CPA CEO, PRESIDENT 1397055 0 2818930 0 2220490 0 2126139 0 24738 0 8587352 0 2179428 0 ANTHONY ROBINSON SVP & CHIEF MKT OFFICER 510892 0 552371 0 657633 0 470718 0 24738 0 2216352 0 644803 0 AMY BASEL SVP, CFO, CRO & TREASURER 484754 0 525138 0 512985 0 421727 0 24738 0 1969342 0 483018 0 SUE ELLEN JENKINS SVP, CHIEF LEGAL OFF, CAO & SEC. 485475 0 528528 0 23018 0 281774 0 15678 0 1334473 0 0 0 TOBY HALL SVP, CHIEF ACTUARY & DATA OFFICER 341819 0 389018 0 25933 0 301204 0 15678 0 1073652 0 0 0 JEFF BOTKIN SVP, BUSINESS SVS 342920 0 368222 0 20533 0 78509 0 17325 0 827509 0 0 0 MARK BAUGHMAN OPERATING CIO 344634 0 367868 0 21284 0 64142 0 17325 0 815253 0 0 0 MICHAEL GILMORE FORMER VP, CHIEF INVEST OFFICER 480021 0 187500 0 21505 0 41121 0 24738 0 754885 0 0 0 KUSHTRIM SHAQIRI VP GOVERNMENT PROGRAMS 346318 0 263616 0 486 0 11110 0 24738 0 646268 0 0 0 JEFFREY JOHNSTON SVP, CHIEF SCIENCE OFFICER 313249 0 143222 0 5367 0 63208 0 24738 0 549784 0 0 0 MIKE BOBAK VP SALES 207726 0 190273 0 5867 0 29204 0 24738 0 457808 0 0 0 DANIEL LOVEJOY DIRECTOR, SALES & ACCT MGT 186255 0 186514 0 1170 0 25082 0 24738 0 423759 0 0 0 MARGARET TRIMER VP STRATEGIC PARTNERSHIPS 237325 0 91260 0 13371 0 53493 0 24738 0 420187 0 0 0 WALTER BUZANOWSKI VP & GENERAL COUNSEL 257044 0 100050 0 532 0 35630 0 24738 0 417994 0 0 0 EARL MAJOR VP HUMAN RESOURCES 20726 0 190273 0 5867 0 29204 0 24738 0 270808 0 0 0 CHRISTOPHER T FISHER DIRECTOR 60000 107004 0 0 0 0 0 0 0 0 60000 107004 0 0 JOSHUA S HOWIE VICE-CHAIRPERSON - THRU 5/21 27500 141468 0 0 0 0 0 0 0 0 27500 141468 0 0 PART I, LINE 1A FIRST CLASS TRAVEL IS AVAILABLE TO SENIOR EXECUTIVES AND KEY EMPLOYEES. THIS AMOUNT WAS TREATED AS NONTAXABLE TO THESE INDIVIDUALS. TRAVEL FOR COMPANIONS RELATED TO TRAVEL FOR A SPOUSE. THIS AMOUNT WAS TREATED AS TAXABLE TO THE BOARD MEMBER OR EMPLOYEE. VARIOUS INDIVIDUALS ON SCHEDULE J ARE ELIGIBLE FOR REIMBURSEMENT OF SUBSTANTIATED HEALTH OR SOCIAL CLUB DUES OR INITIATION FEES THAT HAVE A BUSINESS PURPOSE. THIS BENEFIT IS NOT TAXABLE BUT THE EXPENSE MUST BE SUBSTANTIATED AS A BUSINESS EXPENSE. PART I, LINE 3 THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS REVIEWS PERFORMANCE AND SETS TOTAL COMPENSATION FOR THE CEO WITHOUT THE PRESENCE OR INFLUENCE OF THE CEO. EVERY TWO YEARS, A STUDY IS PERFORMED BY TOWERS WATSON AND THE DATA IS USED IN COMPENSATION DECISIONS. THE INDEPENDENT CONSULTANT PROVIDES AN OPINION AS TO THE REASONABLENESS AND APPROPRIATENESS OF THE TOTAL COMPENSATION, INCLUDING BASE PAY, INCENTIVE, BENEFITS AND RETIREMENT BENEFITS. PART I, LINE 4B DELTA DENTAL PLAN OF MICHIGAN, HAS A SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP). IN ORDER TO BE ELIGIBLE FOR THE SERP, AN EMPLOYEE MUST BE A SENIOR VICE PRESIDENT OR HIGHER AND ADDED TO THE PLAN BY THE BOARD OF DIRECTORS. THE SERP BENEFITS ARE REVIEWED AS PART OF THE TOTAL COMPENSATION BY AN INDEPENDENT CONSULTANT; TOWERS WATSON. IN 2021, GORAN JURKOVIC, AMY BASEL, TOBY HALL, SUE JENKINS, AND ANTHONY ROBINSON ACCRUED BENEFITS AS PARTICIPANTS IN THE SERP PLAN. GORAN JURKOVIC, AMY BASEL, AND ANTHONY ROBINSON BECAME VESTED IN A PORTION OF THEIR ACCRUED BENEFITS AND, AS REQUIRED BY THE IRS, THE VESTED PORTION WAS TREATED AS TAXABLE WAGES DURING 2021. THESE WAGES WERE ALSO REPORTED ON SCHEDULE J AS COMPENSATION THAT HAS BEEN REPORTED AS DEFFERED ON PRIOR FORM 990S. PART I, LINE 7 AS INDICATED IN SCHEDULE J, PART II, TOP MANAGEMENT OFFICIALS RECEIVED A BONUS BASED UPON PERFORMANCE AND THE FINANCIAL RESULTS OF THE ORGANIZATION. THE BONUS WAS APPROVED BY THE EXECUTIVE COMMITTEE OF THE BOARD. BRIAN JACOBSON BROTHER OF FORMER DDPMI BOARD MEMBER JED JACOBSON 263525 EMPLOYEE OF DELTA DENTAL PLAN OF MICHIGAN 0 COLE JACOBSON BROTHER OF FORMER DDPMI BOARD MEMBER JED JACOBSON 149094 EMPLOYEE OF DELTA DENTAL PLAN OF MICHIGAN 0 BRIAN BATTAGLIERI SON OF DDPMI FORMER KEY EMPLOYEE LUIGI BATTAGLIERI 191831 EMPLOYEE OF DELTA DENTAL PLAN OF MICHIGAN 0 STEVEN M DATER DDS BOARD MEMBER AND OWNER OF STEVEN M DATER DDS & ASSOCIATES II, PLC 409646 PAYMENTS FOR DENTAL SERVICES 0 RAYMOND GIST DDS BOARD MEMBER AND OWNER OF RAYMOND GIST DDS PC 198343 PAYMENTS FOR DENTAL SERVICES 0 LARRY DEGROAT DDS BOARD MEMBER AND OWNER OF LARRY DEGROAT DDS 120072 PAYMENTS FOR DENTAL SERVICES 0 FORM 990, PART VI, SECTION A, LINE 6 DELTA DENTAL PLAN OF MICHIGAN HAS A SOLE MEMBER, RENAISSANCE HEALTH SERVICE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7A THE SOLE MEMBER HAS VOTING RIGHTS AND ELECTS DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE SOLE MEMBER HAS THE RIGHTS THAT ARE PRESCRIBED BY LAW, FOR MEMBERS OF NON-PROFIT CORPORATIONS, INCLUDING THE APPROVAL OF SIGNIFICANT EXPENDITURES AND CEO APPOINTMENT. FORM 990, PART VI, SECTION B, LINE 11B THE INFORMATION PRESENTED ON THE FORM 990 IS GATHERED BY THE SENIOR TAX ADMINISTRATOR FOR THE ORGANIZATION. THE CFO REVIEWS THE INFORMATION. ONCE APPROVED, THE INFORMATION IS GIVEN TO OUTSIDE TAX PREPARERS WHO PREPARE AND REVIEW THE FORM 990. ONCE COMPLETE, AN ELECTRONIC COPY OF THE FORM 990 IS PLACED IN A SECURE PORTAL FOR THE BOARD TO REVIEW. THIS IS DONE BEFORE THE RETURN IS FILED WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE COMPANY'S SENIOR VICE PRESIDENT, CHIEF LEGAL OFFICER, AND CAO IS CHARGED WITH REVIEWING AND MONITORING ANY POTENTIAL CONFLICT OF INTEREST TRANSACTIONS. ALL MEMBERS OF THE BOARD OF DIRECTORS, OFFICERS, AND KEY EMPLOYEES ARE REQUIRED TO REVIEW AND EXECUTE A CONFLICT OF INTEREST POLICY. THIS POLICY REQUIRES THAT ANY CONFLICTS OF INTEREST BE DISCLOSED ON AN ANNUAL BASIS, OR AT ANY OTHER TIME THAT THE PERSON EXECUTING THE POLICY BECOMES AWARE OF A SITUATION OR TRANSACTION THAT ACTUALLY OR POTENTIALLY CREATES A CONFLICT OF INTEREST. ALL CONFLICT OF INTEREST DISCLOSURE FORMS ARE INITIALLY REVIEWED BY THE SENIOR VICE PRESIDENT, CHIEF LEGAL OFFICER, AND CAO. IF A PROHIBITED TRANSACTION IS IDENTIFIED, THE MATTER IS ESCALATED TO THE CEO AND TO THE AUDIT, FINANCE, AND RISK MANAGEMENT COMMITTEE OF THE BOARD OF DIRECTORS FOR FURTHER REVIEW AND APPROPRIATE ACTION. IN THE EVENT OF A CONFLICT OF INTEREST INVOLVING A MEMBER OF THE BOARD OF DIRECTORS, SUCH AS A VOTE IN WHICH A MEMBER HAD AN INTEREST, THE MEMBER IS REQUIRED TO DISCLOSE THE POTENTIAL CONFLICT AND ABSTAIN FROM ANY VOTE ON THE MATTER. WHETHER FURTHER PRECAUTIONS ARE REQUIRED (E.G., PROHIBITING THE INTERESTED PARTY FROM ENGAGING IN DISCUSSIONS) WOULD DEPEND UPON THE SPECIFIC NATURE AND BACKGROUND OF THE CONFLICT. FORM 990, PART VI, SECTION B, LINE 15 COMPENSATION OF THE CEO IS DETERMINED BY THE COMPENSATION COMMITTEE OF THE BOARD OF DIRECTORS. COMPENSATION OF THE OTHER EXECTUTIVES IS DETERMINED BY THE CEO IN CONSULTATION WITH THE VP OF HUMAN RESOURCES AND THE CFO. OUTSIDE COMPENSATION CONSULTANTS ARE USED TO DETERMINE MARKET DATA WHICH IS USED TO SET TOTAL COMPENSATION FOR OFFICERS AND KEY EMPLOYEES INCLUDING THE CEO, CFO, AND OTHERS AS APPROPRIATE. DELTA DENTAL PLAN OF MICHIGAN, INC. CONTRACTS WITH TOWERS WATSON TO DO A COMPENSATION AND REASONABLENESS ANALYSIS EVERY TWO YEARS. TOWERS WATSON ALSO PROVIDES AN OPINION AS TO THE REASONABLENESS OF THE TOTAL COMPENSATION PACKAGES, INCLUDING BASE PAY, INCENTIVE, BENEFITS AND RETIREMENT BENEFITS. THE COMPENSATION WAS LAST REVIEWED UNDER THIS PROCESS DURING 2020. COMPENSATION DECISIONS ARE MADE UTILIZING THE DATA PROVIDED BY TOWERS WATSON. FORM 990, PART VI, SECTION C, LINE 19 NO DOCUMENTS AVAILABLE TO THE PUBLIC. FORM 990 PART VII: CERTAIN EMPLOYEES ARE OFFICERS OF MULTIPLE COMPANIES WITHIN THE LARGER ORGANIZATION. THE AVERAGE HOURS WORKED REFLECTS APPROXIMATE TIME SPENT IN EACH OF THOSE INDIVIDUAL COMPANIES. WHILE THE HOURS ARE ALLOCATED TO INDIVIDUAL COMPANIES, MUCH OF THE OFFICERS' TIME IS SPENT WORKING ON ISSUES THAT IMPACT THE ENTIRE ORGANIZATION, NOT JUST ONE COMPANY. COMPENSATION IS REPORTED IN FULL TO AGREE TO THE EMPLOYEE'S W-2 AS REQUIRED BY IRS INSTRUCTIONS. ANY ALLOCATION OF COMPENSATION IS INCLUDED ON SCHEDULE R. FORM 990, PART IX, LINE 11G CONTRACT LABOR: PROGRAM SERVICE EXPENSES 33,216,790. MANAGEMENT AND GENERAL EXPENSES 14,120,302. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 47,337,092. CONTRACTED SERVICES: PROGRAM SERVICE EXPENSES 7,576,859. MANAGEMENT AND GENERAL EXPENSES 5,494,751. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 13,071,610. DENTAL CONSULTANT: PROGRAM SERVICE EXPENSES 1,756,838. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,756,838. PURCHASED DENTAL SERVICES: PROGRAM SERVICE EXPENSES 652,764,133. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 652,764,133. FORM 990, PART XI, LINE 9: GAIN ON EQUITY IN SUBSIDIARIES 1,273,170. PENSION RELATED CHANGES 19,883,187. FORM 990, PART IV, LINE 12A: DELTA DENTAL PLAN OF MICHIGAN RECEIVES AN AUDITED FINANCIAL STATEMENT FROM AN INDEPENDENT ACCOUNTANT BUT THESE STATEMENTS ARE PREPARED ON A STATUTORY BASIS AND NOT IN ACCORDANCE WITH GENERALLY ACCEPTED ACCOUNTING PRINCIPLES (GAAP). 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 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 OF TENNESSEE 240 VENTURE CIRCLE NASHVILLE TN 37228 620812197 PROVIDE DENTAL SERVICE PLANS TN 501(C)(4) N/A RENAISSANCE HEALTH SERVICE CORPORATION 0 DELTA DENTAL FUND PO BOX 30416 LANSING MI 489097916 382337000 SUPPORT DENTAL EDUCATION AND RESEARCH PROGRAMS MI 501(C)(3) LINE 12A, I DELTA DENTAL PLAN OF MICHIGAN INC 1 DELTA DENTAL PLAN OF NEW MEXICO INC 100 SUN AVE NE SUITE 400 ALBUQUERQUE NM 87109 850224562 PROVIDE DENTAL SERVICE PLANS NM 501(C)(4) N/A RENAISSANCE HEALTH SERVICE CORPORATION 0 DELTA DENTAL OF KENTUCKY INC 10100 LINN STATION ROAD NO 700 LOUISVILLE KY 40223 610659432 PROVIDE DENTAL SERVICE PLANS KY 501(C)(4) N/A RENAISSANCE HEALTH SERVICE CORPORATION 0 DELTA DENTAL OF NORTH CAROLINA 4242 SIX FORKS ROAD RALEIGH NC 27609 561018068 PROVIDE DENTAL SERVICE PLANS NC 501(C)(4) N/A RENAISSANCE HEALTH SERVICE CORPORATION 0 DELTA DENTAL PLAN OF ARKANSAS INC 1513 COUNTRY CLUB RD SHERWOOD AR 72120 710561140 PROVIDE DENTAL SERVICE PLANS AR 501(C)(4) N/A RENAISSANCE HEALTH SERVICE CORPORATION 0 DELTA DENTAL OF ARKANSAS FOUNDATION INC 1513 COUNTRY CLUB RD SHERWOOD AR 72120 261569324 EMPHASIZE DENTAL HEALTH IN COMMUNITIES AR 501(C)(3) PF DELTA DENTAL OF ARKANSAS 0 RENAISSANCE FAMILY FOUNDATION INC 4100 OKEMOS RD OKEMOS MI 48864 461376165 EMPHASIZE DENTAL HEALTH IN COMMUNITIES IN 501(C)(3) PF RENAISSANCE HOLDING COMPANY 0 SMILE 180 FOUNDATION 240 VENTURE CIRCLE NASHVILLE TN 37228 471654054 EMPHASIZE DENTAL HEALTH IN COMMUNITIES TN 501(C)(3) LINE 12A, I DELTA DENTAL OF TENNESSEE INC 0 DELTA DENTAL OF KENTUCKY FOUNDATION INC 10100 LINN STATION ROAD SUITE 700 LOUISVILLE KY 40223 874045357 EMPHASIZE DENTAL HEALTH IN COMMUNITIES KY 501(C)(3) PF DELTA DENTAL OF KENTUCKY 0 CHESME LLC 124 N BRIDGE ST DEWITT MI 48820 200061957 CAPITAL MANAGEMENT MI N/A 0 0 RED CEDAR INVESTMENT MANAGEMENT LLC 333 BRIDGE STREET NW SUITE 601 GRAND RAPIDS MI 49546 462667997 CAPITAL MANAGEMENT MI N/A 0 0 DH LOGIX LLC 1000 SOUTH MIAMI TRAIL SARASOTA FL 34236 815265121 CAPITAL MANAGEMENT DE N/A 0 0 RENAISSANCE HOLDING COMPANY PO BOX 30381 LANSING MI 48909 412177193 HOLDING COMPANY MI DELTA DENTAL OF MICHIGAN C -196037 56564756 0.58000 1 RENAISSANCE LIFE & HEALTH INSURANCE COMPANY OF AMERICA PO BOX 30381 LANSING MI 48909 470397286 INSURANCE IN RENAISSANCE HOLDING COMPANY C -1734433 80986244 0.58000 1 RENAISSANCE LIFE & HEALTH INSURANCE COMPANY OF NEW YORK PO BOX 30381 LANSING MI 48909 134098096 INSURANCE NY RENAISSANCE HOLDING COMPANY C 490831 9299123 0.58000 1 FORE HOLDING CORPORATION 240 VENTURE CIRCLE NASHVILLE TN 37228 204116122 HOLDING COMPANY TN N/A C 0 DENTAL CHOICE INC 10100 LINN STATION ROAD SUITE 700 LOUISVILLE KY 40223 611105118 PROVIDE DENTAL SERVICE PLANS KY N/A C 0 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 0 OMEGA ADMINISTRATORS INC 1513 COUNTRY CLUB ROAD SHERWOOD AR 72120 043740469 PROVIDING THIRD-PARTY ADMINISTRATIVE SERVICES AR N/A C 0 THE 4100 GROUP 4100 OKEMOS ROAD OKEMOS MI 48864 472557772 INVESTMENT IN SUBSIDIARIES MI DELTA DENTAL OF MICHIGAN C -908878 102763215 0.75000 1 DEWPOINT INC 300 S WASHINGTON SQUARE LANSING MI 48933 383300595 IT CONSULTING MI THE 4100 GROUP C -622871 36103234 0.75000 1 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 DELTA DENTAL OF TENNESSEE L 5506039 ACTUAL COST DELTA DENTAL PLAN OF OHIO INC L 36901471 ACTUAL COST DELTA DENTAL PLAN OF INDIANA INC L 14544668 ACTUAL COST DELTA DENTAL FUND L 954549 ACTUAL COST RENAISSANCE LIFE AND HEALTH INSURANCE COMPANY OF AMERICA L 5423891 ACTUAL COST DELTA DENTAL PLAN OF NEW MEXICO INC L 2756960 ACTUAL COST DELTA DENTAL OF KENTUCKY INC L 3520685 ACTUAL COST DELTA DENTAL OF NORTH CAROLINA L 5759989 ACTUAL COST DELTA DENTAL PLAN OF ARKANSAS INC L 8065206 ACTUAL COST RENAISSANCE LIFE & HEALTH INSURANCE COMPANY OF NEW YORK L 149131 ACTUAL COST RENAISSANCE HOLDING COMPANY L 726113 ACTUAL COST RENAISSANCE HEALTH SERVICE CORPORATION L 87843 ACTUAL COST DELTA DENTAL FUND B 4000000 ACTUAL COST DEWPOINT L 135749 ACTUAL COST THE 4100 GROUP L 2787883 ACTUAL COST