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ObjectId: 201732989349301348 - Submission: 2017-10-25
TIN: 39-6094742
Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
Attach to Form 990.
Information about Schedule J (Form 990) and its instructions is at
www.irs.gov/form990
.
OMB No. 1545-0047
20
16
Open to Public Inspection
Name of the organization
Delta Dental of Wisconsin Inc
Employer identification number
39-6094742
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
First-class or charter travel
Housing allowance or residence for personal use
Travel for companions
Payments for business use of personal residence
Tax idemnification and gross-up payments
Health or social club dues or initiation fees
Discretionary spending account
Personal services (e.g., maid, chauffeur, chef)
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain
.........
1b
Yes
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked in line 1a?
..
2
Yes
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
Compensation committee
Written employment contract
Independent compensation consultant
Compensation survey or study
Form 990 of other organizations
Approval by the board or compensation committee
4
During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment?
.............
4a
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan?
.........
4b
Yes
c
Participate in, or receive payment from, an equity-based compensation arrangement?
.........
4c
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.
5
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization?
....................
5a
Yes
b
Any related organization?
.......................
5b
No
If "Yes," on line 5a or 5b, describe in Part III.
6
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization?
..................
6a
No
b
Any related organization?
......................
6b
No
If "Yes," on line 6a or 6b, describe in Part III.
7
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed
payments not described in lines 5 and 6? If "Yes," describe in Part III
............
7
No
8
Were any amounts reported on Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III
..........................
8
No
9
If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)?
.........................
9
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2016
Page 2
Schedule J (Form 990) 2016
Page
2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees.
Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note.
The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A)
Name and Title
(B)
Breakdown of W-2 and/or 1099-MISC compensation
(C)
Retirement and other deferred compensation
(D)
Nontaxable
benefits
(E)
Total of columns
(B)(i)-(D)
(F)
Compensation in column (B) reported as deferred on prior Form 990
(i)
Base
compensation
(ii)
Bonus & incentive
compensation
(iii)
Other
reportable compensation
1
Dennis Peterson
Exec VP (through 4/13/16), Pres & CEO (4/14/16-Present)
(i)
(ii)
742,250
-------------
0
186,093
-------------
0
4,824
-------------
0
20,425
-------------
0
37,885
-------------
0
991,477
-------------
0
0
-------------
0
2
Dennis Brown
Pres & CEO (through 4/13/16), Director (4/14/16-Present)
(i)
(ii)
402,570
-------------
0
299,223
-------------
0
1,769
-------------
0
20,425
-------------
0
10,336
-------------
0
734,323
-------------
0
0
-------------
0
3
Doug Ballweg
Treasurer, VP & CFO
(i)
(ii)
407,992
-------------
0
156,376
-------------
0
25,452
-------------
0
316,489
-------------
0
37,982
-------------
0
944,291
-------------
0
0
-------------
0
4
Pamela Gartmann
Secretary and VP - Operations
(i)
(ii)
318,330
-------------
0
114,609
-------------
0
11,407
-------------
0
279,312
-------------
0
18,870
-------------
0
742,528
-------------
0
0
-------------
0
5
David Peterson
VP - Sales & Marketing
(i)
(ii)
349,893
-------------
0
134,955
-------------
0
12,723
-------------
0
380,178
-------------
0
39,250
-------------
0
916,999
-------------
0
0
-------------
0
6
Fred Eichmiller
VP & Science Officer
(i)
(ii)
336,810
-------------
0
130,012
-------------
0
6,513
-------------
0
201,930
-------------
0
34,930
-------------
0
710,195
-------------
0
0
-------------
0
7
Jeff Lutgen
VP - Information Technology
(i)
(ii)
314,604
-------------
0
121,346
-------------
0
6,129
-------------
0
354,288
-------------
0
39,561
-------------
0
835,928
-------------
0
0
-------------
0
8
Anne Treankler
VP, Actuarial & Underwriting
(i)
(ii)
230,006
-------------
0
42,198
-------------
0
4,471
-------------
0
232,474
-------------
0
32,212
-------------
0
541,361
-------------
0
0
-------------
0
9
Sandra Bolz
Senior Account Executive
(i)
(ii)
201,174
-------------
0
12,620
-------------
0
1,354
-------------
0
17,602
-------------
0
26,001
-------------
0
258,751
-------------
0
0
-------------
0
10
Kelly McGinty
Director, Information Technology
(i)
(ii)
187,693
-------------
0
9,746
-------------
0
0
-------------
0
16,255
-------------
0
23,447
-------------
0
237,141
-------------
0
0
-------------
0
11
Brian Pinter
Manager, Applications
(i)
(ii)
175,451
-------------
0
9,123
-------------
0
0
-------------
0
15,314
-------------
0
34,829
-------------
0
234,717
-------------
0
0
-------------
0
12
Steve LeRoy
Senior Sales Executive
(i)
(ii)
239,085
-------------
0
11,480
-------------
0
764
-------------
0
19,588
-------------
0
6,049
-------------
0
276,966
-------------
0
0
-------------
0
13
Lindie Landin
Director, Business Intelligence Data Warehouse
(i)
(ii)
156,119
-------------
0
31,295
-------------
0
0
-------------
0
15,531
-------------
0
35,350
-------------
0
238,295
-------------
0
0
-------------
0
Schedule J (Form 990) 2016
Page 3
Schedule J (Form 990) 2016
Page
3
Part III
Supplemental Information
Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.
Return Reference
Explanation
Schedule J, Part II DEFERRED COMPENSATION
IN PRIOR YEARS, DELTA CONDUCTED AN ANALYSIS OF COMPENSATION PAID AND PROJECTED RETIREMENT BENEFITS TO ITS SENIOR EXECUTIVES. IT WAS DETERMINED THAT THESE SENIOR EXECUTIVES HAD ACCEPTED COMPENSATION AND RETIREMENT BENEFITS BELOW MARKET-RATES FOR SEVERAL YEARS AS THE ORGANIZATION WAS NOT THEN IN A POSITION TO PAY MARKET RATES. THE BOARD AGREED AT THAT TIME TO ESTABLISH A SUPPLEMENTAL RETIREMENT PLAN AND RECEIVED A REASONABLENESS OPINION FROM AN INDEPENDENT COMPENSATION ORGANIZATION. THE COMPENSATION FROM THIS SUPPLEMENTAL RETIREMENT PLAN IS NOTED ON SCHEDULE J, PART II (B), (III). THE AMOUNTS ACCRUED FOR THE CURRENT YEAR ARE REPORTED IN SCHEDULE J, PART II, (C) AND THE AMOUNTS ACCRUED AND REPORTED ON PREVIOUS FORMS 990 ARE REPORTED ON SCHEDULE J, PART II, (F).
Schedule J, Part I, Line 5a
Two employees were partially compensated based on sales revenue in 2016.
Schedule J, Part I, Line 1a First-class or charter travel
On flights exceeding three hours in duration, the CEO is permitted to fly first class. The difference in price between the coach fare and first class is treated as taxable income to the CEO if the flight is under 3 hours in duration.
Schedule J, Part I, Line 1a Travel for companions
Travel for spouses or guests of Delta employees providing a bona fide business service to the organization and/or acting in a host capacity for a company-sponsored event or activity is provided by the Company and is treated as taxable income.
Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan
The organization established non-qualified deferred compensation plans as allowed under IRC Section 457(f) for the benefit of the CEO and senior management team. Changes in the present value of the liabilities under this plan are expensed annually. The benefits payable under the plans totaled $8,930,761 at 12/31/16 and are expected to be paid in 2017 and beyond to participating executives.'' The following officers and employees participated in the section 457(f) plan in 2016: Douglas Ballweg, Pamela Gartman, Fred Eichmiller, Jeff Lutgen, David Peterson, and Anne Treankler.
Schedule J, Part I, Line 5a Compensation contingent on revenues of the organization
Sales employees are eligible to receive incentive compensation based upon revenues earned. The amount of compensation for a particular time period is calculated by applying factors for new and renewal business against the corresponding revenue that each sales employee sold during that period.
Schedule J (Form 990) 2016
Additional Data
Software ID:
16000421
Software Version:
2016v3.0