Dignity Health Workers Compensation Self Insurance Trust

“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, DIGNITY HEALTH, AND ITS RELATED ENTITIES. FORM 990, PART VI, SECTION A, LINE 2 M. BLASZYK AND R. GROSSMAN - BUSINESS RELATIONSHIP R. GROSSMAN AND D. MORISSETTE - BUSINESS RELATIONSHIP FORM 990, PART VI, SECTION A, LINE 7A DIGNITY HEALTH, 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 11B THE ORGANIZATION'S SVP FINANCE & CORPORATE CONTROLLER REVIEWED THE FORM 990. IN ADDITION, THE SUPPORTED ORGANIZATION'S VP OF FINANCIAL SERVICES AND 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 ORGANIZATION HAS ADOPTED DIGNITY HEALTH'S CONFLICTS OF INTEREST POLICY. Under such policies, the EVP/General Counsel is responsible for collecting, reviewing and validating annual disclosures of all covered persons (i.e., Board and Board Committee members, officers and executive leadership, key employees, management personnel at the vice president level and above, and any other personnel at his or her discretion). All covered persons are required to disclose real or potential conflicts arising from the business, financial and personal interests held by such covered persons or their family members. Covered persons are required to disclose to their superiors and to relevant decision makers any interest that may present a conflict, or the appearance of a conflict of interest. Such disclosure is required on a transactional basis at the time such conflicts arise, when an individual becomes a covered person, and annually thereafter. Each covered person is required to certify at least annually that he/she: (1) has received a copy of the policy applicable to his/her position; (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 and assure decisions are made in the organization's best interests. The procedures for addressing a 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 of Directors, members of Board Committees with subject matter jurisdiction and any other relevant decision-makers; (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 interested person 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) the transaction or action is approved by a majority of disinterested persons, consistent with any requirements of bylaws or policies; and (6) any conflicting issues arising during the course of a board meeting which cannot be resolved may be referred to an independent committee of the Board of Directors. There are similar conflicts of interest provisions under the Standards of Conduct, which are applicable to all employees and which are administered by the VP/Corporate Compliance Officer who has reporting resp”

“Description:prof fees for claim process total fees:6980504”

“Description:administrative services total fees:897534”

“Description:actuary services total fees:142220”

“Description:other purchased services total fees:294”