2018-11-15T15:37:41-06:00 2017-12-31 381357951 PLANTE & MORAN PLLC 10 S RIVERSIDE PLAZA 9TH FLOOR CHICAGO IL 60606 990 2017-01-01 860274899 ARIZONA DENTAL INSURANCE SERVICE INC ARIZ 6025883976 5656 WEST TALAVI BLVD GLENDALE AZ 85306 MARK ANDERSON CFO/VICE PRESIDENT 6029383131 2018-11-12 1 DAVID LOWENTHAL P00378651 3122071040 2018-11-12 67.59.56.31 2018-11-12 18:46:25 CS P DA39A3EE5E6B4B0D3255BFEF95601890AFD80709 75C7EC6AC54A61BA087900A4F9B91D17BA572CD0 2017 2019-02-21 02:37:17Z DELTA DENTAL OF ARIZONA MARK ANDERSON 5656 WEST TALAVI BLVD GLENDALE AZ 85306 234442342 0 X WWW.DELTADENTALAZ.COM X 1972 AZ THE CORPORATION EXISTS TO IMPROVE LIVES BY PROMOTING OPTIMAL ORAL HEALTH. 13 11 110 0 38828 5506 0 0 200574272 211691098 1490818 3009969 67823 71732 202132913 214772799 775248 892716 0 0 9050857 9773917 0 0 0 189016990 200417733 198843095 211084366 3289818 3688433 95349963 105072262 18323478 21179537 77026485 83892725 X THE CORPORATION EXISTS TO IMPROVE LIVES BY PROMOTING OPTIMAL ORAL HEALTH. 0 0 71385318 78055858 THE ORGANIZATION PROVIDED DENTAL BENEFIT COVERAGE FOR 274,071 BENEFICIARIES INCLUDED AMONG THESE BENEFICIARIES WERE I) 19,308 INDIVIDUAL ENROLLEES, MANY OF WHOM ARE HIGH-RISK INDIVIDUALS WHO MAY NOT OTHERWISE RECEIVE ACCESS TO AFFORDABLE DENTAL BENEFIT COVERAGE. THESE INDIVIDUALS OBTAINED COVERAGE AS A RESULT OF THE ORGANIZATION'S COLLABORATION WITH CHARITABLE AND GOVERNMENTAL ORGANIZATIONS; II) 53,128 ENROLLEES WHO ARE OR WERE EMPLOYED WITH THE STATE OF ARIZONA, AND III) 117 ENROLLEES WHO WERE ABLE TO OBTAIN COVERAGE THROUGH THE ORGANIZATION'S COLLABORATION WITH ARIZONA SMALL BUSINESS ASSOCIATION. THESE INDIVIDUALS MAY OTHERWISE HAVE BEEN UNABLE TO OBTAIN AFFORDABLE COVERAGE DUE TO THE SIZE OF THE SMALL BUSINESS. THE ORGANIZATION EXPENDED MORE THAN $175 MILLION FOR DENTAL CARE DURING 2017, WITH DENTAL BENEFITS COVERAGE BEING PROVIDED THROUGH CONTRACTS WITH INDEPENDENT PROFESSIONAL DENTAL SERVICE PROVIDERS. 126503758 133635240 AS ITS LARGEST CHARITABLE INITIATIVE, THE ORGANIZATION IS COMMITTED TO EDUCATING THE PUBLIC REGARDING ORAL HEALTH AND WELLNESS. THE ORGANIZATION'S EMPLOYEES PARTICIPATE IN CONTINUING EDUCATION SEMINARS THAT PROVIDE THE TRAINING NECESSARY FOR ORGANIZATION EMPLOYEES TO EDUCATE THE PUBLIC. PUBLIC EDUCATION OCCURS THROUGH IN-PERSON SEMINARS AND THROUGH THE DISSEMINATION OF INFORMATION IN PRINT, AS WELL AS THROUGH TV, RADIO, AND ONLINE AWARENESS EFFORTS. ONE EXAMPLE OF THE ORGANIZATION'S COMMITMENT TO ORAL HEALTH EDUCATION CAN BE VIEWED ON THE WEBSITE HTTP://ORALHEALTHDELTADENTAL.COM/. THE ORGANIZATION MAINTAINS AN ONLINE DATABASE REGARDING ORAL HEALTH TOPICS AND TAILORS ORAL HEALTH INFORMATION TO INDIVIDUALS BY SEGREGATING INFORMATION BY AGE GROUP AND PROVIDING ACCESS TO AN INDIVIDUALIZED DENTAL RISK ASSESSMENT TOOL. THE ORGANIZATION ALSO MAINTAINS A BLOG FOR THE PUBLIC TO PROVIDE ADDITIONAL INFORMATION REGARDING ORAL HEALTH ISSUES. 892716 892716 THE ORGANIZATION ALSO MAKES GRANTS AND DONATES FACILITIES, EQUIPMENT, AND EMPLOYEE TIME TO SUPPORT MANY CHARITABLE CAUSES. DURING 2017, THE ORGANIZATION PROVIDED OR SUPPORTED PREVENTATIVE DENTAL HEALTH SERVICES, CHILDREN'S ORAL HEALTH SERVICE, DENTAL CLINICS, IN-SCHOOL SCREENINGS, TOBACCO AND CHRONIC DISEASE PREVENTION PROGRAMS, EARLY CHILDHOOD PROGRAMS, PRENATAL AND POSTNATAL ORAL HEALTH, AND ACCESS TO DENTAL SERVICES. 198781792 0 0 0 0 0 0 0 0 0 1 1 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 0 0 0 0 0 1 1 1 0 0 1 13412 0 1 110 1 1 1 0 0 0 0 0 0 0 0 0 X 13 11 0 0 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 0 AZ X MARK ANDERSON 6029383131 5656 WEST TALAVI BLVD GLENDALE AZ 85306 BRIEN HARVEY BOARD CHAIR 10.00 0.00 X X 29084 0 0 CANDACE WIEST VICE CHAIR 3.00 0.00 X X 22434 0 0 GARY JONES SECRETARY/TREASURER 3.00 0.00 X X 24000 0 0 DONALD BAKER BOARD MEMBER 3.00 0.00 X 24000 0 0 WILLFORD CARDON BOARD MEMBER 3.00 0.00 X 24000 0 0 DAVID DAY BOARD MEMBER 3.00 0.00 X 21486 0 0 DALE HALLBERG BOARD MEMBER 3.00 0.00 X 24000 0 0 ALVIN MATTHEWS BOARD MEMBER 3.00 0.00 X 24000 0 0 FREDERICK OLSEN BOARD MEMBER 3.00 0.00 X 24000 0 0 WILLIAM PUTNAM BOARD MEMBER 3.00 0.00 X 26667 0 0 JOYCE ROSENTHAL BOARD MEMBER 3.00 0.00 X 24000 0 0 PHILLIP SANTUCCI BOARD MEMBER 3.00 0.00 X 8000 0 0 BRUCE SPIGNER BOARD MEMBER 3.00 0.00 X 24000 0 0 ALLAN ALLFORD PRESIDENT/CEO 40.00 0.00 X 851699 0 155664 MARK ANDERSON VICE PRESIDENT/CFO 40.00 0.00 X 423144 0 90862 CRAIG LIVESAY VICE PRESIDENT 40.00 0.00 X 401750 0 84235 SANDRA ERNST PEREZ VICE PRESIDENT 40.00 0.00 X 247435 0 64722 BRAD CLOTHIER VICE PRESIDENT 40.00 0.00 X 386117 0 11619 SCOTT PEDERSON VICE PRESIDENT 40.00 0.00 X 185630 0 15577 ASHLEE DAILEY CONTROLLER/DIR. OF FINANCE 40.00 0.00 X 157063 0 14375 JEFF NEWBILL SENIOR DATABASE ADMIN 40.00 0.00 X 139658 0 11437 JOHN BRULEY DIRECTOR OF IT 40.00 0.00 X 147553 0 21132 ERIK SKARTVEIT DIRECTOR OF UNDERWRITING 40.00 0.00 X 137896 0 19654 KATHY MORROW DIRECTOR OF PROFESSIONAL RELATIONS 40.00 0.00 X 131499 0 11813 3509115 0 501090 11 0 1 0 DELTA DENTAL OF CA 100 FIRST STREET SAN FRANCISCO CA 94105 SYSTEM IMPLEMENTATION SERVICES 1612500 ENCARA INC 4818 STARKLEY RD ROANOKE VA 24018 ADMINISTERS PRODUCTS 1016937 DELTA DENTAL OF WI PO BOX 828 STEVENS POINT WI 54481 CLAIMS PROCESSING SERVICES 860691 CHANGE HEALTHCARE PO BOX 572490 SALT LAKE CITY UT 84157 FULFILLMENT PAYMENTS 688198 WYSSTA SERVICES INC PO BOX 86 STEVENS POINT WI 54481 ADMINISTRATIVE SERVICES 388530 9 REV - SELF INSUR GROUP 524114 125574985 125574985 DENTAL PREMIUMS 524114 78055858 78055858 COST REIMBURSEMENT 524292 8060255 8060255 211691098 1386987 1386987 21292525 19669543 1622982 1622982 1622982 OTHER INCOME 900099 71732 38828 32904 71732 214772799 211691098 38828 3042873 892716 892716 3218123 1609062 1609061 4949401 4949401 226913 226913 903522 903522 475958 475958 8060255 8060255 108395 108395 157237 157237 272349 272349 9524935 9460256 64679 1183887 1183887 74764 74764 141409 141409 272367 272367 181009 181009 3445 3445 689611 689611 120033 120033 SERVICE TO SELF INSURED 118443503 118443503 PROFESSIONAL DENTAL SVS 57381212 57381212 PREMIUM TAX 1151885 1151885 BANK CHARGES 303170 303170 2348267 1207384 1140883 211084366 198781792 12302574 0 11689447 16594516 17498957 17178223 669463 442371 14172576 6965570 7580082 7207006 43815387 48476368 12993025 13884932 1103602 1288846 95349963 105072262 14690300 17343771 2373038 2426682 20389 57766 1239751 1351318 18323478 21179537 X 77026485 83892725 77026485 83892725 95349963 105072262 X 3688433 3238758 -60951 X 0 1 X 1 0 1530763 1530763 6743785 1712648 5031137 5898028 5252922 645106 7207006 INVESTMENT IN SUBSIDIARY-SOUTHWEST BENEFIT ADM 219518 C INVESTMENT IN SUBSIDIARY-CANYON INSURANCE SVS 632254 C HEDGE FUNDS 13033160 F 13884932 UNCLAIMED PROPERTY LIABILITY 822450 CUSTOMER DEPOSIT LIABILITY 528868 1351318 X 216828954 3238758 -910254 2328504 214500450 272349 272349 214772799 210808572 0 210808572 272349 3445 275794 211084366 PART X, LINE 2: MANAGEMENT EVALUATES THE COMPANY'S EXPOSURE FOR UNCERTAIN TAX POSITIONS AT EACH REPORTING PERIOD. AS OF DECEMBER 31, 2017 AND 2016, MANAGEMENT BELIEVES THE COMPANY HAS NO MATERIAL UNCERTAIN TAX POSITIONS AND THEREFORE NO SUCH LIABILITIES HAVE BEEN RECORDED. PART XI, LINE 2D - OTHER ADJUSTMENTS: LOSSES FROM CONSOLIDATED RELATED PARTIES -906,809. INTEREST EXPENSE -3,445. PART XII, LINE 4B - OTHER ADJUSTMENTS: INTEREST EXPENSE 3,445. 1 DELTA DENTAL PLAN OF ARIZONA CHARITABLE FOUNDATION AND TRUST 5656 WEST TALAVI BLVD GLENDALE AZ 85306 860842694 501(C)(3) 817152 ANNUAL CONTRIBUTION BASED ON BOARD DIRECTIVE TO PROMOTE ORAL HEALTH 1 0 PART I, LINE 2: THE ORGANIZATION'S BOARD RECEIVES REGULAR REPORTS ON THE ORGANIZATION'S ACTIVITIES AND EXPENDITURES OF GRANT FUNDS DONATIONS ARE MADE TO ESTABLISHED, WELL-RESPECTED, LOCAL PUBLIC CHARITY ORGNAIZATIONS. AS A RESULT, ONGOING MONITORING OF THE USE OF GRANT FUNDS IS NOT CONSIDERED NECESSARY. X X 1 1 X X X X X X 0 1 0 1 0 1 0 1 0 ALLAN ALLFORD PRESIDENT/CEO 506066 0 207000 0 138633 0 129060 0 26604 0 1007363 0 0 0 MARK ANDERSON VICE PRESIDENT/CFO 304944 0 111000 0 7200 0 63997 0 26865 0 514006 0 0 0 CRAIG LIVESAY VICE PRESIDENT 244849 0 85775 0 71126 0 57808 0 26427 0 485985 0 0 0 SANDRA ERNST PEREZ VICE PRESIDENT 158017 0 34998 0 54420 0 40980 0 23742 0 312157 0 0 0 BRAD CLOTHIER VICE PRESIDENT 310117 0 70000 0 6000 0 7390 0 4229 0 397736 0 0 0 SCOTT PEDERSON VICE PRESIDENT 167630 0 18000 0 0 0 0 0 15577 0 201207 0 0 0 ASHLEE DAILEY CONTROLLER/DIR. OF FINANCE 136713 0 20350 0 0 0 0 0 14375 0 171438 0 0 0 JEFF NEWBILL SENIOR DATABASE ADMIN 130742 0 8916 0 0 0 0 0 11437 0 151095 0 0 0 JOHN BRULEY DIRECTOR OF IT 127203 0 20350 0 0 0 0 0 21132 0 168685 0 0 0 ERIK SKARTVEIT DIRECTOR OF UNDERWRITING 120696 0 17200 0 0 0 0 0 19654 0 157550 0 0 0 PART I, LINE 1A 1. FIRST CLASS TRAVEL - ALL SENIOR EXECUTIVES ARE OFFERED THIS BENEFIT FOR BUSINESS TRAVEL EXCEEDING 4 HOURS AND IT IS NOT TREATED AS TAXABLE COMPENSATION. 2. TRAVEL FOR COMPANIONS - THE PRESIDENT/CEO RECEIVES THIS BENEFIT AND IT IS TREATED AS TAXABLE COMPENSATION. PART I, LINE 4B THE ORGANIZATION HAS A NONQUALIFIED DEFERRED COMPENSATION PLAN FOR CERTAIN MEMBERS OF SENIOR MANAGEMENT AS DETERMINED BY THE DDAZ BOARD. PLAN BALANCES ARE CREDITED AT THE DISCRETION OF THE BOARD. THE FOLLOWING INDIVIDUALS RECEIVED A CONTRIBUTION TO OR DISTRIBUTION FROM THE NON QUALIFIED DEFERRED COMPENSATON PLAN. ALLAN ALLFORD - $129,060 CONTRIBUTION; $129,633 DISTRIBUTION MARK ANDERSON - $63,997 CONTRIBUTION CRAIG LIVESAY - $57,808 CONTRIBUTION; $71,126 DISTRIBUTION SANDRA ERNST PEREZ - $40,980 CONTRIBUTION; $54,420 DISTRIBUTION BRAD CLOTHIER - $7,390 CONTRIBUTION PART I, LINE 5 CONSISTENT WITH THE ORGANIZATION'S OVERALL COMPENSATION PHILOSOPHY, OFFICERS, HIGHLY COMPENSATED, AND OTHER DESIGNATED EMPLOYEES PARTICIPATE IN AN ORGANIZATION INCENTIVE COMPENSATION PLAN. THE PLAN CONTAINS METRICS WHICH REPRESENT STRATEGIC PLAN MEASURES THAT ARE DETERMINED ANNUALLY BY THE BOARD OF DIRECTORS. AN OVERALL WEIGHTED SCORE IS CALCULATED BASED ON ACHIEVING A RANGE OF PLAN MEASURES, AMONG WHICH ARE INCENTIVES RELATED TO REVENUE GOALS. PART I, LINE 6 CONSISTENT WITH THE ORGANIZATION'S OVERALL COMPENSATION PHILOSOPHY, OFFICERS, HIGHLY COMPENSATED, AND OTHER DESIGNATED EMPLOYEES PARTICIPATE IN AN ORGANIZATION INCENTIVE COMPENSATION PLAN. THE PLAN CONTAINS METRICS WHICH REPRESENT STRATEGIC PLAN MEASURES THAT ARE DETERMINED ANNUALLY BY THE BOARD OF DIRECTORS. AN OVERALL WEIGHTED SCORE IS CALCULATED BASED ON ACHIEVING A RANGE OF PLAN MEASURES, AMONG WHICH ARE INCENTIVES RELATED TO REVENUE GOALS. PART I, LINE 7 CONSISTENT WITH THE ORGANIZATION'S OVERALL COMPENSATION PHILOSOPHY, THE COMPENSATION OF OFFICERS AND HIGHLY COMPENSATED EMPLOYEES INCLUDE THE POTENTIAL FOR A BONUS BASED UPON FURTHERING THE CHARITABLE PURPOSES OF THE ORGANIZATION. THIS GOAL INCLUDES PRESERVATION OF INCOME WHICH PROVIDES THE ORGANIZATION WITH THE RESOURCES NECESSARY TO ACCOMPLISH ITS CHARITABLE PURPOSES. DALE HALLBERG DIRECTOR 282441 CONTRACTED PROVIDER PAYMENTS WERE MADE TO BOARD MEMBER DALE HALLBERG CONSISTENT WITH REGULAR COMPANY REIMBURSEMENT RATES. 0 BRUCE SPIGNER DIRECTOR 107160 CONTRACTED PROVIDER PAYMENTS WERE MADE TO BOARD MEMBER BRUCE SPIGNER CONSISTENT WITH REGULAR COMPANY REIMBURSEMENT RATES. 0 FORM 990, PART VI, SECTION A, LINE 6 ANY ETHICAL DENTIST DULY LICENSED AND IN GOOD STANDING IN THE STATE OF ARIZONA IS ELIGIBLE TO BE A MEMBER OF THE ORGANIZATION. MEMBERS ELECT THE BOARD OF DIRECTORS. MEMBERS DO NOT HAVE AN OWNERSHIP INTEREST IN THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 7A MEMBERS OF THE ORGANIZATION HAVE AUTHORITY TO ELECT DELTA DENTAL'S GOVERNING BODY. NO OTHER GROUP OR PERSON CAN VOTE FOR THOSE WHO SERVE ON THE ORGANIZATION'S GOVERNING BODY. FORM 990, PART VI, SECTION A, LINE 7B THESE BYLAWS MAY BE ALTERED, AMENDED OR REPEALED AND NEW BYLAWS MAY BE ADOPTED ONLY BY THE AFFIRMATIVE VOTE OF TWO THIRDS OF THE MEMBERS PRESENT AT A MEETING OF THE MEMBERS AT WHICH A QUORUM IS PRESENT. FORM 990, PART VI, SECTION B, LINE 11B THE ORGANIZATION HAS A PROCESS FOR THE GOVERNING BODY TO RECEIVE AND REVIEW THE 990 BEFORE IT IS FILED. THAT PROCESS INCLUDES THE FOLLOWING STEPS 1. MANAGEMENT'S ENGAGEMENT OF OUTSIDE PROFESSIONAL SERVICES TO PREPARE AND DRAFT THE FORM 990. 2. MANAGEMENT'S REVIEW OF THE DRAFT FORM 990 TO CHECK FOR ACCURACY. 3. THE REVIEW OF THE DRAFT FORM 990 BY THE COMPANY'S AUDIT AND INVESTMENT COMMITTEE. 4. PROVIDING THE PROPOSED FINAL DRAFT OF THE FORM 990 TO THE BOARD OF DIRECTORS BEFORE FILING THE DOCUMENT WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A POLICY IN PLACE TO MONITOR AND ENFORCE COMPLIANCE WITH ITS CONFLICT OF INTEREST POLICIES WHICH COVER BOTH BOARD MEMBERS AND EMPLOYEES UPON HIRE AND ANNUALLY. THEREAFTER, MEMBERS OF THE GOVERNING BOARD ARE REQUIRED TO EXECUTE THE CONFLICT OF INTEREST POLICY. UPON HIRE, EMPLOYEES ARE REQUIRED TO EXECUTE THE CONFLICT OF INTEREST POLICY. THE ORGANIZATION HAS PROCEDURES IN PLACE TO REMIND EMPLOYEES AND OFFICERS/DIRECTORS OF THE COMPANY OF THE POLICY AND OF THE NEED TO BE ATTENTIVE TO THE POSSIBILITY OF NEWLY CREATED CONFLICTS OF INTEREST. FURTHER, IN CONNECTION WITH THE ORGANIZATION'S DUE DILIGENCE ASSOCIATED WITH THE PREPARATION OF FILING OF THE FORM 990, A SEPARATE PROCESS IS USED TO OBTAIN INFORMATION FROM DIRECTORS AND EMPLOYEES TO ENABLE THE ORGANIZATION TO ASSESS THE EXISTENCE OF TRANSACTIONS OR RELATIONSHIPS THAT SHOULD BE DISCLOSED BY THE ORGANIZATION. POTENTIAL AND ACTUAL CONFLICTS INVOLVING EMPLOYEES OTHER THAN THE CEO AND CFO ARE REVIEWED BY THE CEO AND CFO POTENTIAL AND ACTUAL CONFLICTS OF THE CEO, CFO, AND BOARD MEMBERS ARE REVIEWED BY THE EXECUTIVE COMMITTEE OF THE BOARD. IN ALL INSTANCES INVOLVING AN ACTUAL CONFLICT OF INTEREST, THE CONFLICTED EMPLOYEE OR BOARD MEMBER IS ASKED TO RECUSE HIMSELF FROM DELIBERATIONS ABOUT THE POTENTIAL TRANSACTION. FORM 990, PART VI, SECTION B, LINE 15 THE ORGANIZATION HAS A PROCESS IN PLACE FOR INDEPENDENT CONSULTANTS TO REVIEW AND REPORT ON COMPENSATION OF THE CEO, OFFICERS, KEY EMPLOYEES, AND BOARD MEMBER COMPENSATION WITH FINAL REVIEW AND APPROVAL BY THE BOARD OF DIRECTORS. THIS INCLUDES REVIEW OF COMPARABILITY, DATA, AND OBTAINING THE INDEPENDENT CONSULTANT'S OPINION OF THE REASONABLENESS OF COMPENSATION DECISIONS MADE BY THE ORGANIZATION. INDEPENDENT CONSULTANT REVIEWS ARE PERFORMED FOR EXECUTIVE STAFF AND BOARD COMPENSATION EVERY TWO YEARS. THE INDEPENDENT CONSULTANT'S REPORT AND THE AFFIRMATION OF DISINTERESTED BOARD MEMBERS IS DOCUMENTED IN WRITING IN THE BOARD MINUTES. REVIEWS WERE LAST PERFORMED IN 2018. FORM 990, PART VI, SECTION C, LINE 19 AS REQUIRED BY ARIZONA STATE LAW, THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. THE ORGANIZATION DOES NOT MAKE ITS CONFLICT OF INTEREST STATEMENT AVAILABLE TO ITS MEMBERS OR TO THE PUBLIC. MEMBERS OF THE PUBLIC MAY OBTAIN COPIES OF THE ARTICLES OF INCORPORATION FROM THE ARIZONA CORPORATION COMMISSION. MEMBERS OF THE PUBLIC ALSO MAY OBTAIN COPIES OF DELTA DENTA'S STATUTORY FINANCIAL STATEMENTS FROM THE ARIZONA DEPARTMENT OF INSURANCE AND FROM THE NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS. FORM 990, PART XI, LINE 9: LOSSES FROM CONSOLIDATED RELATED PARTIES -60,951. 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