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ObjectId: 202003219349308200 - Submission: 2020-11-16
TIN: 22-1896118
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.
Go to
www.irs.gov/Form990
for instructions and the latest information.
OMB No. 1545-0047
20
19
Open to Public Inspection
Name of the organization
DELTA DENTAL OF NEW JERSEY INC
Employer identification number
22-1896118
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 on 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 on 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
Yes
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
No
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
Yes
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) 2019
Page 2
Schedule J (Form 990) 2019
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 G WILSON
PRESIDENT/CEO
(i)
(ii)
701,303
-------------
0
384,104
-------------
0
207,643
-------------
0
47,280
-------------
0
43,721
-------------
0
1,384,051
-------------
0
0
-------------
0
2
LORI A ACKER
SVP OPERATIONS
(i)
(ii)
319,072
-------------
0
145,281
-------------
0
211,700
-------------
0
44,434
-------------
0
15,406
-------------
0
735,893
-------------
0
0
-------------
0
3
KEITH D LIBOU
CHIEF CLINICAL OFFICER
(i)
(ii)
343,658
-------------
0
106,928
-------------
0
187,522
-------------
0
43,325
-------------
0
43,141
-------------
0
724,574
-------------
0
0
-------------
0
4
JAMES SULESKI
SENIOR VP/CFO
(i)
(ii)
362,328
-------------
0
162,051
-------------
0
50,222
-------------
0
45,447
-------------
0
45,801
-------------
0
665,849
-------------
0
0
-------------
0
5
PAUL J DIMAIO ESQ
SVP/GENERAL COUNSEL
(i)
(ii)
348,330
-------------
0
161,160
-------------
0
21,723
-------------
0
45,312
-------------
0
46,506
-------------
0
623,031
-------------
0
0
-------------
0
6
KATHLEEN A FENNELL-BORGES
SVP HUMAN RESOURCES
(i)
(ii)
250,829
-------------
0
111,291
-------------
0
196,939
-------------
0
42,992
-------------
0
16,906
-------------
0
618,957
-------------
0
0
-------------
0
7
VINCENT FARINELLA
VP STRATEGY & PRODUCT DEVELOP
(i)
(ii)
278,263
-------------
0
99,051
-------------
0
130,562
-------------
0
42,321
-------------
0
18,106
-------------
0
568,303
-------------
0
0
-------------
0
8
RANDY M STODARD
VP/CMO
(i)
(ii)
290,145
-------------
0
78,642
-------------
0
11,876
-------------
0
42,772
-------------
0
48,006
-------------
0
471,441
-------------
0
0
-------------
0
9
STEVEN FLEISCHER
VP/CSO (TERMED 2/20/19)
(i)
(ii)
42,334
-------------
0
41,985
-------------
0
265,238
-------------
0
41,559
-------------
0
41,654
-------------
0
432,770
-------------
0
0
-------------
0
10
KIM WHITE-WAPELHORST
ACCOUNT EXECUTIVE
(i)
(ii)
179,781
-------------
0
140,396
-------------
0
2,016
-------------
0
42,821
-------------
0
49,429
-------------
0
414,443
-------------
0
0
-------------
0
11
JOHN GUMKOWSKI
VP (TERMED 4/8/2019)
(i)
(ii)
72,118
-------------
0
38,424
-------------
0
225,059
-------------
0
42,952
-------------
0
31,040
-------------
0
409,593
-------------
0
0
-------------
0
12
JEFF FURBISH
VP/CSO (EFF 3/4/2019)
(i)
(ii)
196,872
-------------
0
51
-------------
0
141,467
-------------
0
36,400
-------------
0
33,997
-------------
0
408,787
-------------
0
0
-------------
0
13
JUSTIN LAHULLIER
CIO/VP INFORMATION SERVICES
(i)
(ii)
235,856
-------------
0
62,421
-------------
0
7,704
-------------
0
47,600
-------------
0
45,037
-------------
0
398,618
-------------
0
0
-------------
0
14
THOMAS C KAHLER
VP (TERMED 5/3/2019)
(i)
(ii)
68,474
-------------
0
38,000
-------------
0
202,482
-------------
0
42,591
-------------
0
46,375
-------------
0
397,922
-------------
0
0
-------------
0
15
ALLAN BERKIN
ACCOUNT EXECUTIVE
(i)
(ii)
181,919
-------------
0
90,766
-------------
0
4,132
-------------
0
47,600
-------------
0
46,306
-------------
0
370,723
-------------
0
0
-------------
0
16
WENDY WALKER
GENERAL MANAGER
(i)
(ii)
209,651
-------------
0
24,590
-------------
0
11,588
-------------
0
40,430
-------------
0
41,878
-------------
0
328,137
-------------
0
0
-------------
0
17
MICHAEL RODRIGUES
VP ACCOUNTING
(i)
(ii)
234,000
-------------
0
31,974
-------------
0
1,644
-------------
0
44,060
-------------
0
2,460
-------------
0
314,138
-------------
0
0
-------------
0
18
DAVID ATHA
ASSISTANT VICE PRESIDENT
(i)
(ii)
213,097
-------------
0
34,175
-------------
0
950
-------------
0
43,204
-------------
0
16,529
-------------
0
307,955
-------------
0
0
-------------
0
19
DOREEN PILIGIAN
AVP & ASSOCIATE GEN COUNSEL
(i)
(ii)
199,874
-------------
0
35,380
-------------
0
619
-------------
0
44,487
-------------
0
15,406
-------------
0
295,766
-------------
0
0
-------------
0
20
RONALD I DEBLINGER DMD
CHAIRMAN - TRUSTEE
(i)
(ii)
0
-------------
0
0
-------------
0
257,321
-------------
0
0
-------------
0
9,405
-------------
0
266,726
-------------
0
0
-------------
0
21
BARRY PETRUZZI
VP UNDERWRITING
(i)
(ii)
156,984
-------------
0
51
-------------
0
10,221
-------------
0
36,400
-------------
0
30,163
-------------
0
233,819
-------------
0
0
-------------
0
Schedule J (Form 990) 2019
Page 3
Schedule J (Form 990) 2019
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 I; QUESTIONS 1A AND 1B
THE ORGANIZATION'S PRESIDENT/CEO TRAVELS FIRST CLASS ON BUSINESS RELATED FLIGHTS EXCEEDING THREE HOURS TO ATTEND ORGANIZATION RELATED WORK EVENTS. THIS PROVIDES THE PRESIDENT/CEO THE ABILITY TO WORK ON ORGANIZATIONAL MATTERS DURING TRAVEL. THE EXCESS COST OVER STANDARD RELATED TO THE 1ST CLASS TRAVEL WAS NOT INCLUDED IN HIS 2019 FORM W-2, BOX 5, AS TAXABLE MEDICARE WAGES. THE ORGANIZATION PAID FOR FINANCIAL/TAX PLANNING SERVICES FOR CERTAIN EMPLOYEES. THE FINANCIAL/TAX PLANNING SERVICES AMOUNTS OUTLINED HEREIN WERE INCLUDED IN EACH INDIVIDUAL'S RESPECTIVE 2019 FORM W-2, BOX 5, AS TAXABLE MEDICARE WAGES: DENNIS G. WILSON, $750; PAUL J. DIMAIO, $525; KATHLEEN FENNELL-BORGES, $450 AND THOMAS C. KAHLER, $750. EACH OF THE FOLLOWING INDIVIDUAL'S 2019 FORM W-2 INCLUDES A GROSS-UP AMOUNT RELATED TO THE PERSONAL USAGE OF AN AUTO ALLOWANCE; DENNIS G. WILSON $6,782, LORI A. ACKER $6,126, KEITH LIBOU $4,586, JAMES SULESKI $5,650, PAUL J. DIMAIO $5,650, KATHLEEN FENNELL-BORGES $6,126, RANDY M. STODARD $4,657 AND WENDY WALKER $4,657. IN ADDITION, CERTAIN BOARD OF TRUSTEE MEMBERS' 2019 FORMS 1099-MISC INCLUDE TAX GROSS-UP PAYMENTS RELATED TO COMPENSATION PAID TO THEM FOR PERSONAL USAGE OF AN AUTO AND/OR FINANCIAL/TAX PLANNING SERVICES.
SCHEDULE J, PART I; QUESTION 4A
THE FOLLOWING INDIVIDUALS RECEIVED A SEVERANCE PAYMENT DURING CALENDAR YEAR 2019 WHICH WAS INCLUDED IN EACH INDIVIDUAL'S 2019 FORM W-2, BOX 5 AS TAXABLE MEDICARE WAGES: STEVEN FLEISCHER, $206,595; JOHN GUMKOWSKI, $124,386 AND THOMAS C. KAHLER $161,068.
SCHEDULE J, PART I; QUESTION 4B
THE AMOUNTS REFLECTED IN COLUMN B(III) FOR THE FOLLOWING INDIVIDUALS INCLUDE PARTICIPATION IN A PENSION RESTORATION supplemental executive retirement PLAN ("SERP") BECAUSE THE AMOUNTS ARE NO LONGER SUBJECT TO A SUBSTANTIAL RISK OF COMPLETE FORFEITURE. THE AMOUNTS OUTLINED HEREIN WERE INCLUDED IN EACH INDIVIDUAL'S 2019 FORM W-2, BOX 5, AS TAXABLE MEDICARE WAGES: DENNIS G. WILSON, $191,940; LORI A. ACKER, $197,043; KEITH D. LIBOU, $175,386; JAMES SULESKI, $36,450; KATHLEEN A. FENNELL-BORGES, $182,301; VINCENT FARINELLA, $129,943; STEVEN FLEISCHER, $13,200; JOHN GUMKOWSKI, $49,152 AND JUSTIN LAUHULLIER, $7,560. PLEASE NOTE THAT THE AMOUNTS REFLECTED INCLUDE A 27% TAX ADJUSTMENT WITH RESPECT TO THE SERP PAYMENTS TO MITIGATE THE TAX INEFFICIENCY OF THE NON-QUALIFIED SERP.
SCHEDULE J, PART I; QUESTION 7 AND CORE FORM, PART VII
INCLUDED IN COLUMN B(II) FOR CERTAIN INDIVIDUALS IS A PAYMENT RELATED TO A PROGRESS INCENTIVE PROGRAM. UNDER THIS PROGRAM, A PAYMENT IS MADE TO THESE INDIVIDUALS WHICH IS BASED ON ESTABLISHED TARGETS, BENCHMARKS AND GOALS. IF MET, THE INDIVIDUALS RECEIVE, AS A PROGRESS INCENTIVE PAYMENT, ADDITIONAL COMPENSATION BASED ON A PERCENTAGE OF THEIR BASE COMPENSATION. THE ABOVE NOTED PAYMENT WAS INCLUDED IN EACH INDIVIDUAL'S 2019 FORM W-2, BOX 5, AS TAXABLE MEDICARE WAGES. PLEASE REFER TO THIS SECTION OF THE FORM 990, SCHEDULE J FOR THIS INFORMATION BY PERSON BY AMOUNT.
Schedule J (Form 990) 2019
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