2012-05-14T13:21:12-05:00 2011-06-30 KPMG LLP 55 SECOND STREET SUITE 1400 SAN FRANCISCO CA 94105 990 2010-07-01 946612446 Catholic Healthcare West Workers' Compensation Self-Insurance Trust CATH 4154385500 185 Berry Street San Francisco CA 94107 MARY CONNICK 2012-05-11 4159635100 2010 2016-02-24 21:20:13Z MICHAEL BLASZYK 185 BERRY STREET SAN FRANCISCO CA 94107 919934590 false 0928 X WWW.CHWHEALTH.ORG X 1989 CA SELF-INSURED WORKERS' COMPENSATION FOR RELATED EXEMPT ORGANIZATIONS 0 0 0 0 4467 3186 0 0 45927875 13140251 15195003 30032673 0 0 61122878 43172924 0 0 0 0 0 0 0 0 0 39131375 55618158 39131375 55618158 21991503 -12445234 372868451 409856659 277763194 309764077 95105257 100092582 SELF-INSURED WORKERS' COMPENSATION FOR RELATED EXEMPT ORGANIZATIONS. false false 52141755 0 13140251 ADMINISTRATION OF SELF-INSURANCE PROGRAMS FOR WORKERS' COMPENSATION FOR AFFILIATED CHARITABLE HEALTHCARE ORGANIZATIONS. 52141755 true false false false false false false false false false true false false true false false true false false true false false false false false false false false true false false false false false false false false false false false false false true false false false false true X 1779 0 true 0 true true true GR KS MY PL false false false false false false false false X 0 0 true false false false false true true true true false false false true true true true true false false false CA X MARY CONNICK FINANCE DEPT 4154385500 185 BERRY STREET SAN FRANCISCO CA 94107 X STATE STREET X 121195 548894 0 Michael D Blaszyk 2.0 X 0 2419590 525537 Derek F Covert 2.0 X 0 1093842 106794 Lloyd H Dean 2.0 X 0 3907346 1229537 Mary Connick 2.0 X 0 566987 64289 Hillery Trippe 32.0 X 0 380730 38683 Robert Wiebe 2.0 X 0 1187920 219942 121195 10105309 2184782 1 false true false SEDGWICK CLAIMS 3850 VINE ST 2ND FLOOR RIVERSIDE CA 925074269 Management Services 5046868 HANNA BROPHY MACLEAN MCALEER AND JE FILE 30939 PO BOX 60000 SAN FRANCISCO CA 94160 Legal Svcs 224469 LUNA AND LEVERING 71 PEARL ST MONTEREY CA 93940 Legal Svcs 194196 WILSON PESOTA AND PICHARDO 200 W SANTA ANA BLVD STE 970 SANTA ANA CA 92701 Legal Svcs 180005 STOCKWELL HARRIS WOOLVERTON AND MUE 3580 WILSHIRE BLVD STE 1900 LOS ANGELES CA 90010 LEGAL SERVICES 144074 11 0 MGMT FEE FOR SVCS RELATED TO WORKERS' 900099 13140251 13140251 COMP EXPS 13140251 11611842 4467 11607375 0 0 895182497 876761666 18420831 18420831 18420831 0 0 0 0 43172924 13140251 4467 30028206 0 0 0 0 0 0 0 0 0 0 0 0 22870 22870 0 0 1415596 1415596 7873150 6858649 1014501 0 41281 41281 0 0 0 0 0 0 0 0 0 0 TAXES AND LICENSES 982155 982155 WORKERS' COMPENSATION 45270917 45270917 CLAIMS EXPENSE OTHER EXPENSES 12189 12189 55618158 52141755 3476403 0 1571019 1571429 15108588 14663319 20655416 26067926 298216732 328821537 37294329 38732448 22367 0 372868451 409856659 57836028 74825376 219927166 234938701 277763194 309764077 X 95105257 100092582 95105257 100092582 372868451 409856659 X -12445234 17432559 X false true true X false X X X false false false CATHOLIC HEALTHCARE WEST 941196203 03 true true true 55618158 1 55618158 The Trust provided or purchased for the benefit of Catholic Healthcare West, various services, facilities and goods. See Form 990, Part IX for further details. POOLED INVESTMENTS 38732448 F 38732448 0 WORKERS' COMP LIABILITIES 234937977 DUE TO RELATED PARTIES 724 234938701 East Asia and the Pacific 0 0 Investments N/A 6295050 Europe (Including Iceland and Greenland) 0 0 Investments N/A 42068478 North America 0 0 Investments N/A 2046692 Sub-Saharan Africa 0 0 Investments N/A 118215 0 0 0 0 50528435 50528435 false false true false true false false true false false false false false false false Michael D Blaszyk 0 848704 0 1349501 0 221385 0 471958 0 53579 0 2945127 0 201590 Derek F Covert 0 526077 0 553216 0 14549 0 64451 0 42343 0 1200636 0 0 Lloyd H Dean 0 1322045 0 2050325 0 534976 0 1154351 0 75186 0 5136883 0 509948 Mary Connick 0 349426 0 208061 0 9500 0 38905 0 25384 0 631276 0 0 Hillery Trippe 0 192686 0 105613 0 82431 0 24640 0 14043 0 419413 0 0 Robert Wiebe 0 577145 0 603375 0 7400 0 193236 0 26706 0 1407862 0 0 Part I, Line 3, 4A & 4b PART I, LINE 3 The Organization relied on a related organization, Catholic Healthcare West, that used one or more of the methods described in Schedule J, Part I, Line 3, to establish the Organization's top management official's compensation. See Schedule O disclosure for Form 990, Part VI, Section B, Line 15 for additional information. PART I, LINE 4a Catholic Healthcare West Workers'Compensation Self-Insurance Trust's officers and key employees participate in a severance plan that provides market-standard compensation, ranging from payments of 6 months to 2 years of base compensation, depending on the executive's position, in the event of a position elimination or other involuntary termination, in accordance with the guidelines of the plan. No payments were made to any officers and key employees during 2010 pursuant to this plan. PART I, LINE 4B Catholic Healthcare West Workers'Compensation Self-Insurance Trust's officers and key employees are eligible to participate in one of two non-qualified 457(f) plans that are subject to substantial risk of forfeiture, as required by the IRS. The 2007 Executive Deferred Compensation Plan is for executives hired prior to June 30, 2006. The benefit is intended to bridge the difference, if any, between the benefit provided under the CHW Excess Benefit Plan had benefit service not been frozen at January 1, 2008, and the benefits provided from all other qualified and non-qualified plans. No benefit under this formula will vest under this 457(f) plan before the attainment of age 62 or the completion of 15 years of service. The 2010 Executive Deferred Compensation Plan is for three officers and key employees who are not eligible to participate in the CHW Excess Benefit Plan or the 2007 Executive Deferred Compensation Plan described above. This benefit provides an annual accrual of 10% of total compensation and is payable annually on July 1 once vested, which is age 62 with 5 years of service. No payments were made under either plan during 2010. Certain officers and key employees participate in the CHW Excess Benefit Plan, a nonqualified supplemental benefit plan limited to participants in the CHW Retirement Plan whose benefits are affected by the limitations imposed by sections 401(a)(17) and 415 of the Internal Revenue Code. Benefit service under this plan was frozen as of January 1, 2008. No payments were made to any listed persons during 2010 pursuant to this plan. Certain listed persons participate in the CHW Key Employee Share Option Plan (KeySOP), which was frozen in May 2002. The KeySOP program was established in 2001 with the purpose of providing income deferral opportunities to employees eligible for the company's key employee retention program. No payments were made under this plan during 2010. Certain officers and key employees participate in the CHW Supplemental Executive Retention/Retirement Plan, a nonqualified supplemental benefit plan which in 2002 was offered to members of the executive management team by the CHW Board of Directors and would be paid only if the executives stayed with the organization for a specified number of years as the primary purpose of this plan is to provide for the retention and retirement of the participants. The executive management team was recruited from stable careers in organizations from across the country and from various industries to engineer and lead a financial and operational turnaround after the organization had lost nearly $1 billion in net operating performance. The calculation for the payments to each executive is based on the value of a final average pay annuity benefit based on retirement age and service years to the organization. Distribution occurs each July 1 if the plan formula warrants a payment. Vested amounts are reported as deferred compensation in the year vesting occurs (Schedule J, Part II, column C) and are reflected again as reportable compensation in the year paid (Schedule J, Part II, column B(iii)). Payments made during 2010 pursuant to this plan include $509,948 to L. Dean, $201,590 to M. Blaszyk and $174,625 to E. Shih. Part II - Additional Information CHW's executive compensation philosophy is designed to assist CHW in attracting and retaining the caliber of executives required to enable CHW to fulfill its mission of providing high quality healthcare for all persons regardless of their ability to pay for services, improving the quality of life in the communities CHW serves, promoting patient and employee satisfaction, and ensuring financial stability. A substantial portion of executive compensation is performance based and is linked to organizational goals approved in advance by the Human Resources and Compensation Committee. These goals include attainment of annual and long-term financial performance, certain healthcare quality standards and CHW's commitment to serving the poor and disenfranchised in the communities it serves. Total compensation, which includes base salary, annual and long-term incentive compensation, targets the 75th percentile of the market in which CHW competes for executives, commensurate with the size and complexity of the organization. FORM 990, PART VI - GOVERNANCE, MANAGEMENT, DISCLOSURE FORM 990, PART VI, SECTION A, LINE 2 Officer D. Covert has a family relationship with key employee M. Connick. FORM 990, PART VI, SECTION A, LINE 7a Catholic Healthcare West (CHW), the Trustor of the organization, has the power to appoint and remove the institutional trustee. FORM 990, PART VI, SECTION A, LINE 7b The Trustor may amend, alter or revoke the trust agreement in whole or in part at any time. FORM 990, PART VI, SECTION B, LINE 11A The ORGANIZATION's VP Finance & Corporate Controller REVIEWED THE FORM 990. IN ADDITION, THE SUPPORTED ORGANIZATION'S Senior Director of Financial Reporting WORKED CLOSELY WITH an independent, OUTSIDE accounting firm engaged to review the Form 990. The final VERSION OF THE FORM 990 WAS NOT provided to the INSTITUTIONAL TRUSTEE before the return was filed. FORM 990, PART VI, SECTION B, LINE 12C The Board of Directors OF CATHOLIC HEALTHCARE WEST, THE SUPPORTED ORGANIZATION, delegated to the Audit and Compliance Committee responsibility for monitoring conflicts of interest disclosures and addressing any potential or actual conflicts. CHW's conflict of interest policy charges the EVP/General Counsel with responsibility for reviewing and validating disclosures, and maintaining adequate records of disclosures. Pursuant to the conflicts of interest policy, an annual conflict of interest disclosure statement, aimed at determining any family and business relationships and transactions, or other transactions that may pose a potential conflict, is distributed to all covered persons (e.g., board members, officers and executive leadership, key employees and all management personnel whose responsibilities include business decisions which may give rise to conflicts of interest). Covered persons are also required to disclose real or potential conflicts at the time such conflicts arise. When an individual becomes a covered person and annually thereafter, each covered person is required to submit an updated disclosure statement and to sign a statement affirming that he/she: (1) has received a copy of the conflicts of interest policy; (2) has read the policy and understands said policy; and (3) agrees to comply with all requirements of the policy, including completing the conflicts of interest disclosure statement. As required by the policy, the President/CEO and EVP/General Counsel prepare annual reports of reported conflicts of interest which are provided to the Board of Directors, committee chairs, and key leaders of the organization to enable responsible individuals to monitor and manage disclosed conflicts of interest in the organization's best interests. The procedures for addressing any conflict of interest related to a proposed transaction include, but are not limited to, the following: (1) the conflicting interest is fully disclosed to the board; (2) the interested person responds to factual questions related to the substance of the transaction or arrangement being considered, after which he/she shall leave the meeting; (3) the person with the conflict of interest is excluded from the discussion and approval of such transaction; (4) if warranted, alternatives to the proposed transaction are investigated, and competitive bids or comparable valuations are obtained; (5) any conflicting issues arising during the course of a board meeting which cannot be resolved are to be referred to an independent committee of the Board of Directors; and (6) the transaction or action must be approved by a majority of disinterested persons. FORM 990, PART VI, SECTION B, LINE 15 Although the organization does not directly employ any personnel, the supported organization's Board of Directors ANNUALLY appoints a Human Resources and Compensation Committee, comprised solely of directors who are independent with respect to executive compensation, to be accountable for setting reasonable compensation packages for each officer or key employee (including the President/CEO). The Human Resources and Compensation Committee approves, consistent with the organization's philosophy and principles, the annual performance goals and criteria to be used in determining merit increases and variable compensation criteria for officers and key employees. The Human Resources and Compensation Committee also engages outside legal counsel, as necessary, and a qualified independent compensation and benefits specialist (independent expert) to review, analyze and provide benchmarking data for the total compensation and benefits packages of officers and key executives. Appropriate comparability data is obtained from the independent experts, e.g., total economic benefits paid by similarly situated organizations (both taxable and tax-exempt) for similar job responsibilities. Key deliberations of the committee are documented in meeting minutes which are approved at the next committee meeting and provided to the Board of Directors. THE DOCUMENTATION OF THE DECISION INCLUDES (A) THE TERMS OF THE TRANSACTION THAT WAS APPROVED AND THE DATE IT WAS APPROVED, (B) THE MEMBERS OF THE COMMITTEE WHO WERE PRESENT DURING DEBATE ON THE TRANSACTION THAT WAS APPROVED AND THOSE WHO VOTED ON IT, AND (C) THE COMPARABILITY DATA OBTAINED AND RELIED UPON BY THE COMMITTEE AND HOW THE DATA WAS OBTAINED. FORM 990, PART VI, SECTION C, LINE 19 Federal tax laws do not mandate that the organization's governing documents, conflict of interest policy and financial statements be made available for public inspection. The organization IS INCLUDED IN CATHOLIC HEALTHCARE WEST AND SUBORDINATE CORPORATIONS' CONSOLIDATED financial statements WHICH ARE available on CHW'S website and upon request. FORM 990, PART V, LINE 2a The organization does not have employees. The organization operates as the administration company of the workers' compensation self-insurance program for the supported organization Catholic Healthcare West and its related entities. FORM 990, PART XI, LINE 5 Change in unrealized gains; $18,583,120 Book/Tax difference K-1 investments; $(1,150,561) HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Michael D Blaszyk TITLE:EVP Chief Financial Officer HOURS:40 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Derek F Covert TITLE:EVP Legal Svcs/General Counsel HOURS:40 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Lloyd H Dean TITLE:President/ CEO HOURS:40 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Mary Connick TITLE:VP, Finance Corp Controller HOURS:40 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Hillery Trippe TITLE:VP, Risk Services HOURS:8 HOURS DEVOTED FOR RELATED ORGANIZATION FORM 990 PART VII NAME:Robert Wiebe TITLE:VP, Chief Medical Officer HOURS:40 Catholic Healthcare West 185 Berry Street San Francisco CA 94107 941196203 Hospital CA 501(c)(3) 3 NA CHW Hospital & Professional Liability Se 185 BERRY STREET SAN FRANCISCO CA 94107 943006034 ADMINISTRATIO CA 501(c)(3) 11; Type 1 NA false false false false false false false false false false false false false true false true false NONE