2018-11-15T14:47:07-06:00 2017-12-31 540504608 BROWN EDWARDS & COMPANY LLP 319 MCCLANAHAN STREET SW ROANOKE VA 24014 990 2017-01-01 540844477 DELTA DENTAL OF VIRGINIA DELT 5409898000 4818 STARKEY ROAD ROANOKE VA 240188542 R JAMES BARKER VICE PRESIDENT OF FINANCE 5409898000 2018-11-05 1 M C WINGFIELD P00005971 5403450936 2018-11-05 206.248.228.130 2018-11-05 15:54:00 ES P D0156BD46B4B1FE921C9503B1D7FFBF99E37DBAB CE530EA759AC3AF6BB0EECEF8950573E07121913 2017 2019-02-21 02:37:17Z R JAMES BARKER 4818 STARKEY ROAD ROANOKE VA 240188542 716799585 0 X WWW.DELTADENTALVA.COM X 1964 VA IMPROVE THE PUBLIC'S ORAL HEALTH. 12 9 66 0 0 0 0 0 672966134 697888912 1685156 2258068 0 0 674651290 700146980 0 0 0 0 9172034 9249089 0 0 0 646716652 670088270 655888686 679337359 18762604 20809621 147037134 168014567 61380170 65793844 85656964 102220723 ADVANCE THE PUBLIC'S ORAL HEALTH BY PROVIDING QUALITY DENTAL BENEFITS AT AFFORDABLE COST. 0 0 614961799 697888912 GROUP AND INDIVIDUAL PREPAID DENTAL CARE WAS 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806697 320610 13335923 60833 1494083 1155488 399428 2322231 2197145 125086 3095912 3095912 0 18258905 SOFTWARE UPGRADE 20159587 OTHER ASSETS 5576191 25735778 DEPOSITS 4780524 ADV. PREMIUMS AND DEPOSITS 24768671 RATE STABILIZATION RESERVE 809710 DENTAL SERVICE CLAIMS RESERVES 11369608 OPTION LIABILITY 1576388 43304901 X 700051227 0 700051227 188040 -92287 95753 700146980 679241606 0 679241606 188040 -92287 95753 679337359 PART X, LINE 2: INCOME TAXES FOOTNOTE: DELTA IS EXEMPT FROM FEDERAL INCOME TAX UNDER THE PROVISIONS OF PUBLIC LAW 99-514, TAX REFORM ACT OF 1986, ACT SECTION 1012(C)(4)(C)(IV) AND HAS RECEIVED A FAVORABLE DETERMINATION LETTER FROM THE IRS UNDER CODE SECTION 501(C)(4). THE FOUNDATION IS EXEMPT FROM FEDERAL INCOME TAXES UNDER CODE SECTION 501(C)(3). PART XI, LINE 4B - OTHER ADJUSTMENTS: REAL ESTATE HOLDING COSTS -92,287. PART XII, LINE 4B - OTHER ADJUSTMENTS: REAL ESTATE HOLDING COSTS -92,287. X X 1 1 X X X X X X 0 1 0 1 0 0 0 1 0 DR GEORGE A LEVICKI PRESIDENT, RETIRED NOV 2017 0 587010 0 455347 0 154994 0 54000 0 17596 0 1268947 0 0 MR R JAMES BARKER VICE PRESIDENT OF FINANCE 0 291577 0 143143 0 620 0 54000 0 17662 0 507002 0 0 MR PETER V DAVIES II SVP & COO 447618 0 231464 0 34555 0 54000 0 15638 0 783275 0 0 0 DR JOSEPH M DILL DDS VICE PRESIDENT 237640 0 77439 0 1844 0 34047 0 17539 0 368509 0 0 0 MR BRADLEY KNOPF VICE PRESIDENT 226469 0 116900 0 1292 0 34047 0 19992 0 398700 0 0 0 MR CHRISTOPHER PYLE VICE PRESIDENT 196479 0 61995 0 462 0 32940 0 22650 0 314526 0 0 0 MR DAVID WERNER VICE PRESIDENT 72450 0 376567 0 2944 0 34047 0 17388 0 503396 0 0 0 MS MELISSA KIRSH STAFF 40200 0 335346 0 579 0 34047 0 19992 0 430164 0 0 0 MR MATTHEW MACDONALD STAFF 37450 0 225430 0 119 0 33479 0 22542 0 319020 0 0 0 MR JASON REYNOLDS STAFF 36850 0 192469 0 416 0 21712 0 8812 0 260259 0 0 0 MR BRIAN SHIELDS STAFF 49916 0 216692 0 148 0 33305 0 20075 0 320136 0 0 0 MR JOHN WILSON STAFF 34200 0 218982 0 1042 0 32027 0 5962 0 292213 0 0 0 DR FRENCH H MOOREJR FORMER DIRECTOR 22694 0 0 0 0 0 0 0 0 0 22694 0 0 0 MR THOMAS S NARDO FORMER DIRECTOR 22672 0 0 0 0 0 0 0 0 0 22672 0 0 0 DR GRANT M SPRINKLE III FORMER DIRECTOR 22755 0 0 0 0 0 0 0 0 0 22755 0 0 0 MR MICHAEL L HOULISTON FORMER DIRECTOR 699 22500 0 0 0 0 0 0 0 0 699 22500 0 0 DR MAYER G LEVY FORMER DIRECTOR 0 22500 0 0 0 0 0 0 0 0 0 22500 0 0 DR EMANUEL W MICHAELS FORMER DIRECTOR 0 22500 0 0 0 0 0 0 0 0 0 22500 0 0 DR ALBERT L PAYNE FORMER DIRECTOR 255 22500 0 0 0 0 0 0 0 0 255 22500 0 0 PART I, LINE 1A FIRST-CLASS OR CHARTER TRAVEL-WE FOLLOW ADOPTED POLICY FOR BOTH FIRST-CLASS OR CHARTER TRAVEL. IN SUMMARY, FIRST-CLASS TRAVEL IS NOT ALLOWED EXCEPT BY SPECIFIC GUIDANCE IN THE T & E POLICY (I.E. EXCEPTIONALLY LONG FLIGHT, ETC.) TRAVEL FOR COMPANIONS-WE FOLLOW ADOPTED CORPORATE TRAVEL AND ENTERTAINMENT (T&E) POLICY FOR COMPANIONS. IN SUMMARY, SPOUSAL TRAVEL IS NOT COVERED UNLESS SPECIFIC CRITERIA IS MET. HEALTH OR SOCIAL CLUB DUES,IF ANY, ARE DETERMINED VIA THE COMPENSATION & BENEFITS REVIEW BY THE MANAGEMENT DEVELOPMENT AND COMPENSATION COMMITTEE OF THE BOARD. AS NOTED, THE EXECUTIVE COMPENSATION AND BENEFITS REVIEW IS IN ACCORDANCE WITH THE PROCESS OUTLINED BY THE IRS FOR SETTING REASONABLE COMPENSATION. PART I, LINE 4B THE FOLLOWING LUMP SUM PAYMENTS BY THIS ORGANIZATION AND A RELATED ORGANIZATION HAVE BEEN INCLUDED IN COLUMN B-III OF SCHEDULE J, PART II. THE LUMP SUM PAYMENTS IN 2017 WERE EARNED OVER A PRECEDING MULTI-YEAR PERIOD. THESE PLANS WERE ESTABLISHED VIA THIS ORGANIZATION'S AND THE RELATED ORGANIZATION'S MANAGEMENT DEVELOPMENT & COMPENSATION COMMITTEE'S COMPENSATION AND BENEFIT REVIEW WHICH IS IN ACCORDANCE WITH THE PROCESS OUTLINED BY THE IRS FOR SETTING REASONABLE COMPENSATION. THESE PLANS ARE IN ACCORDANCE WITH SUPPLEMENTAL NONQUALIFIED DEFERRED COMPENSATION PLANS AS PER IRS SECTION 457(F). THE FOLLOWING AMOUNTS WERE PAID FROM THIS ORGANIZATION AND A RELATED ORGANIZATION IN 2017: EMPLOYEE AMOUNT DR. GEORGE A. LEVICKI, RELATED ORG PAYMENT $142,092 MR. PETER V. DAVIES II $30,324 PART I, LINE 5 PART I, LINE 5A: THE FOLLOWING EMPLOYEES RECEIVED SALES COMMISSIONS IN 2017 IN THEIR ROLES AS SALES MANAGEMENT AND STAFF BASED UPON REVENUE GENERATED DIRECTLY BY EACH RESPECTIVE INDIVIDUAL: DAVID WERNER $376,567 MELISSA KIRSH $335,346 MATTHEW MACDONALD $225,430 JOHN WILSON $218,982 BRIAN SHIELDS $216,692 JASON REYNOLDS $192,469 THESE AMOUNTS WERE SUBJECT TO REVIEW BY THE HUMAN RESOURCES DEPARTMENT FOR FAIRNESS AND REASONABILITY. PART I, LINE 7 A PORTION OF THE PERSON'S COMPENSATION IS AT RISK PROVIDING KEY METRICS AND GOALS ARE ACHIEVED. THE RESPECTIVE PROGRAMS ARE SUBJECT TO THE MANAGEMENT DEVELOPMENT & COMPENSATION COMMITTEE'S COMPENSATION AND BENEFIT REVIEW PROCESS WHICH IS IN ACCORDANCE WITH THE PROCESS OUTLINED BY THE IRS FOR SETTING REASONABLE COMPENSATION. G SPRINKLE III FAMILY DENTISTRY PC PARTICIPATING DENTIST 270550 DENTAL CLAIMS 0 DRS MCILVEEN & FREEDMAN PC PARTICIPATING DENTIST 203854 DENTAL CLAIMS 0 FORM 990, PART VI, SECTION A, LINE 6 DELTA DENTAL OF VIRGINIA IS A NON-STOCK CORPORATION ORGANIZED UNDER TITLE 13.1 OF THE CODE OF VIRGINIA. CORVESTA, INC. IS THE SOLE MEMBER OF DDVA AS DEFINED IN SECTION 13.1-803 OF THE CODE OF VIRGINIA. FORM 990, PART VI, SECTION A, LINE 7A THE MEMBER ELECTS THE BOARD OF DIRECTORS. FORM 990, PART VI, SECTION A, LINE 7B THE MEMBER VOTES ON QUESTIONS OF MERGER, CONSOLIDATION OR DISSOLUTION OF THE CORPORATION; AND AMENDING THE ARTICLES OF INCORPORATION. FORM 990, PART VI, SECTION B, LINE 11B DIRECTORS ON THE BOARD OF DIRECTORS WILL REVIEW THE DOCUMENT WITH SENIOR MANAGEMENT MEMBERS. THE REVIEW WILL BE DOCUMENTED AT THE SUBSEQUENT BOARD MEETING. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF DIRECTORS AND OFFICERS COMPLETE CONFLICT OF INTEREST FORMS ANNUALLY. THE BOARD CHAIRMAN REVIEWS THE DIRECTORS' FORMS, THE NOMINATING COMMITTEE CHAIRMAN REVIEWS THE BOARD CHAIRMAN'S FORM AND THE PRESIDENT REVIEWS THE OFFICERS' FORMS. ALL ARE FILED IN THE CORPORATE MINUTE BOOK WHICH IS REVIEWED BY OUR AUDITORS AND THE BOI. FORM 990, PART VI, SECTION B, LINE 15 THE MANAGEMENT DEVELOPMENT & COMPENSATION COMMITTEE OF THE BOARD HAS BEEN DELEGATED RESPONSIBILITY FOR SETTING SENIOR EXECUTIVE COMPENSATION AND BENEFITS. THE COMMITTEE'S MEMBERS ARE DDVA OUTSIDE DIRECTORS. THEY MUST BE INDEPENDENT OF MANAGEMENT AND FREE OF ANY RELATIONSHIPS THAT, IN THE OPINION OF THE BOARD OF DIRECTORS, WOULD INTERFERE WITH THE EXERCISE OF THEIR INDEPENDENT JUDGEMENT AS COMMITTEE MEMBERS WITH RESPECT TO THE TRANSACTIONS AND OTHER MATTERS THAT THEY ARE CALLED UPON TO EVALUATE. THE COMMITTEE HAS ENGAGED AND USES AN OUTSIDE, INDEPENDENT SENIOR EXECUTIVE COMPENSATION EXPERT TO ASSIST IN ESTABLISHING SENIOR EXECUTIVE COMPENSATION AND BENEFITS. THE OUTSIDE CONSULTANT PROVIDES, AMONG OTHER INFORMATION AND ADVICE, COMPARABLE DATA (FORM 990 AND OTHER COMPENSATION STUDIES) OF PEER ORGANIZATIONS. THIS COMMITTEE MEETS BETWEEN 3 AND 4 TIMES PER YEAR. MINUTES OF ALL MEETINGS ARE KEPT IN ACCORDANCE WITH IRS GUIDELINES. FORM 990, PART VI, SECTION C, LINE 19 THE APPLICABLE FORMS ARE AVAILABLE FOR PUBLIC INSPECTION VIA REQUEST AND REGULATORY FILINGS. FORM 990, PART XI, LINE 9: SURPLUS TRANSFER TO HOLDING COMPANY -5,000,000. FORM 990, PART XII, LINE 2C THERE HAVE BEEN NO CHANGES TO DELTA DENTAL OF VIRGINIA'S OVERSIGHT PROCESS OF THE AUDIT OR ITS SELECTION OF AN INDEPENDENT AUDITOR. CORVESTA INC 4818 STARKEY ROAD ROANOKE VA 240188542 205945158 HOLDING COMPANY VA 501(C)(4) N/A 0 DELTA DENTAL OF VIRGINIA FOUNDATION 4818 STARKEY ROAD ROANOKE VA 240188542 453230862 PROMOTION AND ADVANCEMENT OF ORAL HEALTH FOR THE PEOPLE OF VA VA 501(C)(3) LINE 12A, I DELTA DENTAL OF VIRGINIA 1 CORVESTA SOFTWARE SOLUTIONS PVT LTD 4818 STARKEY ROAD ROANOKE VA 240188542 PROVIDES SOFTWARE DEVELOPMENT & PROGRAMMING IN N/A C 0 REVOLV INC 4818 STARKEY ROAD ROANOKE VA 240188542 271018474 PROVIDES TPA SERVICES TO DENTAL INSURANCE COMPANIES VA N/A C 0 CORVESTA LIFE INSURANCE COMPANY INC 4818 STARKEY ROAD ROANOKE VA 240188542 860201136 PROVIDES LIFE INSURANCE COVERAGE AZ N/A C 0 1 1 0 0 0 0 0 0 0 1 0 0 0 1 0 1 1 1 1 DELTA DENTAL OF VIRGINIA FOUNDATION B 459868 FAIR MARKET VALUE