2012-11-12T10:47:19-06:00 2011-12-31 010494526 BAKER NEWMAN & NOYES LLC 650 ELM STREET SUITE 302 MANCHESTER NH 03101 990 2011-01-01 030219391 Delta Dental Plan Of Vermont Inc DELT 6032231000 PO Box 2002 Concord NH 033022002 THOMAS RAFFIO 6032231000 2012-11-07 E Drew Cheney P00182972 8002447444 2011 2016-02-24 21:20:13Z Thomas Raffio PO Box 2002 Concord NH 033022002 61160018 0 X www.nedelta.com X 1965 VT Provide programs of dental care 16 11 0 0 100000 0 0 0 52812991 55318342 504430 605894 98445 0 53415866 55924236 165500 151300 46275363 46833344 437012 468488 0 0 0 5760289 6174768 52638164 53627900 777702 2296336 17418509 19090797 2654601 2389111 14763908 16701686 It is our mission to be the leading force in the dental prepayment market by offering quality, versatile and affordable dental programs to benefit our purchasers, subscribers, and participating member dentists. 0 0 48884437 55218342 Program services include the processing and payment of claims for dental programs for various organizations. Approximately 291,000 claims were processed in 2011. There were approximately 143,900 members included in the various plans. 151300 151300 Grant made to the Northeast Delta Dental Foundation ($151,300). 49035737 0 0 0 0 0 0 0 0 0 1 0 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 1 112 0 1 0 1 1 0 0 0 0 0 X 16 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X Frank Boucher 6032231000 One Delta Drive PO Box 2002 Concord NH 03302 DAVID M ANDERSON 3.00 X X 20050 0 0 CLAYTON R ADAMS 3.00 X X 7183 0 0 LAWRENCE G JENSEN 3.00 X X 4828 0 0 JOHN L WESTBROOK DDS 3.00 X X 5740 0 0 PAUL A AVERILL DDS 3.00 X 7183 0 0 DAVID A BAASCH DDS 3.00 X 3816 0 0 PAULA L COPE 3.00 X 6321 0 0 MICHAEL R DICK DMD 3.00 X 1443 0 0 GREGORY H ELLIS DMD 3.00 X 6221 0 0 JUDITH M FISCH DDS 3.00 X 3816 0 0 PHILIP A LAPP CPA 3.00 X 4999 0 0 SUZANNE M MCDOWELL 3.00 X 3335 0 0 BRENDA L NEEDHAM 3.00 X 3385 0 0 LEEANN PODRUCH DDS 3.00 X 481 0 0 WILLIAM D PURDY DDS MS 3.00 X 6702 0 0 JAMES T RUDE 3.00 X 1924 0 0 CHARLES P SMITH 3.00 X 6702 0 0 NEVIN ZABLOTSKY DMD 3.00 X 5790 0 0 THOMAS RAFFIO - DDPNH 10.00 X 0 708515 135902 WILLIAM H LAMBRUKOS - DDPNH 10.00 X 0 170046 29159 99919 878561 165061 0 0 1 1 Combined Services LLC 15 North Main Street Suite 300 Concord NH 03301 Insurance broker commissions 530318 Hickok & Boardman 346 Shelburne Road PO Box 1064 Burlington VT 05402 Insurance broker commissions 117693 2 Admin Service Contract 524292 29605421 29605421 Premium Revenue 524114 25612921 25612921 Management fee - CSLLC 524298 100000 100000 55318342 395681 395681 5445995 5235782 210213 210213 210213 55924236 55218342 100000 605894 151300 151300 46833344 46833344 99919 99919 265232 265232 5364 5364 78567 78567 19406 19406 27377 27377 16784 16784 53274 53274 26300 26300 173527 173527 64487 64487 38765 38765 20918 20918 67854 67854 4301 4301 15359 15359 Administration - DDPNH 4256790 2043259 2213531 Brokers' Commissions 1300456 1300456 Dues & subscriptions 90455 90455 Professional Relations 6600 6600 11521 7834 3687 53627900 49035737 4592163 0 1722278 2830200 377489 276101 1027600 1402563 4575 4215 86000 85034 5267 966 12848984 13111385 1352030 1392668 80286 72699 17418509 19090797 1419641 1189000 39000 123600 1195960 1076511 2654601 2389111 X 14763908 16701686 14763908 16701686 17418509 19090797 X 2296336 -358558 X X 0 1 1 X 0 38906 37940 966 47094 47094 0 966 Investment in Red Tree Holdings (1/3 interest) 1392668 F 1392668 Unearned Revenue 336111 Other Advances 740400 1076511 55924236 53627900 2296336 -358558 -358558 1937778 28078512 -358558 -358558 28437070 53274 27433892 27487166 55924236 26140734 0 26140734 53274 27433892 27487166 53627900 Description of Uncertain Tax Positions Under FIN 48: Part X: The 2011 audited financial statements contain the following verbatim paragraphs pertaining to tax positions under FIN 48: The Corporation is exempt from federal and state income taxes under the provisions of Section 501(c)(4) of the Internal Revenue Code. Tax-exempt organizations could be required to record an obligation for income taxes as the result of a tax position historically taken on various tax exposure items including unrelated business income or tax status. In accordance with accounting principles generally accepted in the United States of America, assets and liabilities are established for uncertain tax positions taken or positions expected to be taken in income tax returns when such positions are judged to not meet the "more-likely-than-not" threshold, based upon the technical merits of the position. Management has evaluated the Corporation's tax positions taken on its filed tax returns and concluded that the Corporation has maintained its tax-exempt status, does not have any significant unrelated business income and has taken no uncertain tax positions that require adjustment to or disclosure in the accompanying financial statements. Tax years after December 31, 2007 are open for Internal Revenue Service or state examination. Part XII, Line 4b - Other Adjustments: Dental claims paid under admin service contracts 27,433,892. Part XIII, Line 4b - Other Adjustments: Dental claims paid under admin service contracts 27,433,892. 1 Northeast Delta Dental Foundation One Delta Drive PO Box 2002 Concord NH 03302 020489150 501(c)(3) 151300 General support to promote oral health Delta Dental Plan of Vermont, Inc. (DDPVT) makes elective annual charitable contributions to the Northeast Dental Foundation equal to 0.05% of the budgeted gross billings, plus 5% of the actual increase in unrestricted net assets from operations each year. DDPVT's elective contributions to the Foundation in 2011 totaled $151,300. X X X X X 0 1 0 0 0 0 0 0 0 THOMAS RAFFIO - DDPNH 0 522200 0 131700 0 54615 0 111750 0 24152 0 844417 0 0 WILLIAM H LAMBRUKOS - DDPNH 0 155377 0 4978 0 9691 0 5268 0 23891 0 199205 0 0 Supplemental Information Part III Thomas Raffio, CEO, and William Lambrukos, Senior Vice President, both receive all of their compensation from Delta Dental Plan of New Hampshire, which is an unrelated organization per Schedule R definitions. Michael R Dick DMD Trustee 304687 The trustees listed here have ownership interests in dental practices that receive insurance reimbursements from Delta Dental in the ordinary course of their business. All transactions are at arm's length and for fair value. 0 Gregory H Ellis DMD Trustee 144741 0 0 William D Purdy DDS Trustee 744176 0 Paul A Averill DDS Trustee 171178 0 David A Baasch DDS Trustee 138856 0 Judith M Fisch DDS Trustee 189402 0 Form 990, Part VI, Section B, line 11 The Form 990 is reviewed in detail by key finance employees of Northeast Delta Dental. A final draft is presented to the Board before the Form is filed. Form 990, Part VI, Section B, line 12c A copy of the conflict of interest policy is distributed annually to all officers, trustees, and the management team. All are required to report any conflicts and sign, date, and return the policy, whether or not a conflict exists, to confirm compliance. General Counsel reviews the returned policies and reports the results to the entire Board of Trustees. The trustees are asked to provide updates of any changes that may occur between their annual conflict of interest filings. Form 990, Part VI, Section C, line 19 Upon request, Delta Dental Plan of Vermont, Inc. makes its governing documents, conflict of interest policy, or financial statements available to the public. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 5: Net unrealized losses on investments: -358,558. Audit Review Process Form 990, Part XII, Line 2c: The Finance/Audit Committee oversees the audit process for Delta Dental Plan of Vermont. The audit process for the financial statements did not change from the prior year. Independent accountants performed the audit in both 2010 and 2011.