Attach to Form 990 or Form 990-EZ.
Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
| (i)Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) | (iv) Is the organization listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| (A)
RIDDLE MEMORIAL HOSPITAL |
231529076 | Yes | 0 | 0 | ||
| (B)
MAGEE REHABILITATION HOSPITAL |
231476328 | Yes | 0 | 0 | ||
| (C)
MAIN LINE HOSPITALS INC |
231352160 | Yes | 0 | 0 | ||
| (D)
THOMAS JEFFERSON UNIVERSITY HOSPITAL |
232829095 | Yes | 0 | 0 | ||
| (E)
ARIA HEALTH |
230596940 | Yes | 0 | 0 | ||
Total 5
|
0 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .... | ||||||
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....... | ||||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 4 | Total. Add lines 1 through 3 | ||||||
| 5 | The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f).. | ||||||
| 6 | Public support. Subtract line 5 from line 4. | ||||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | ||||||
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | ||||||
| 9 | Net income from unrelated business activities, whether or not the business is regularly carried on.. | ||||||
| 10 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.).. | ||||||
| 11 | Total support Add lines 7 through 10. | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | ||||||
| 2 | Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose...... | ||||||
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513.. | ||||||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | ||||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 6 | Total. Add lines 1 through 5. | ||||||
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons... | ||||||
| b | Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year. | ||||||
| c | Add lines 7a and 7b.. | ||||||
| 8 | Public support (Subtract line 7c from line 6.) | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2010 | (b) 2011 | (c) 2012 | (d) 2013 | (e) 2014 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | ||||||
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | ||||||
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | ||||||
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | ||||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) .. | ||||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | ||||||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e | Discount claimed for blockage or other factors (explain in detail in Part VI): | |||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by .035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| 7 | Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions) | |||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | ||
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
||
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | ||
| 4 Amounts paid to acquire exempt-use assets | ||
| 5 Qualified set-aside amounts (prior IRS approval required) | ||
| 6 Other distributions (describe in Part VI). See instructions | ||
| 7Total annual distributions. Add lines 1 through 6. | ||
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
||
| 9 Distributable amount for 2014 from Section C, line 6 | ||
| 10 Line 8 amount divided by Line 9 amount | ||
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2014 |
(iii) Distributable Amount for 2014 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2014 from Section C, line 6 |
||||
|
2
Underdistributions, if any, for years prior to 2014 (reasonable cause required--see instructions) |
||||
| 3 Excess distributions carryover, if any, to 2014: | ||||
| a From 2009.......X | ||||
| b From 2010.......X | ||||
| c From 2011.......X | ||||
| d From 2012.......X | ||||
| e From 2013....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2014 distributable amount | ||||
|
i
Carryover from 2009 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2014 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2014 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2014, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions) |
||||
|
6
Remaining underdistributions for 2014. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
||||
|
7 Excess distributions carryover to 2015. Add lines 3j and 4c. |
||||
| 8 Breakdown of line 7: | ||||
| a From 2010.......X | ||||
| b From 2011.......X | ||||
| c From 2012.......X | ||||
| d From 2013....... | ||||
| e From 2014....... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| Schedule A, Part I, Line 11h(vii) | FIVE POINTE PROFESSIONAL LIABILITY INSURANCE COMPANY PROVIDES EXCESS AND REINSURANCE PROFESSIONAL LIABILITY INSURANCE COVERAGE AND RELATED INSURANCE SERVICES FOR THE SUPPORTED ORGANIZATIONS DESCRIBED HEREIN. |
| Software ID: | 14000329 |
| Software Version: | 2014v1.0 |
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at| Return Reference | Explanation |
|---|---|
| Form 990, Part VI, Line 1b | EFFECTIVE JUNE 30, 2014, THE MEMBERS ARE MAIN LINE HOSPITALS, INC. (44%), RIDDLE MEMORIAL HOSPITAL (4%), THOMAS JEFFERSON UNIVERSITY HOSPITALS, INC. (48%), MAGEE REHABILITATION HOSPITAL (2%), AND ARIA HEALTH (2%). THE VOTING MEMBERS OF THE ORGANIZATION'S GOVERNING BODY DO NOT QUALIFY AS INDEPENDENT UNDER IRS DEFINITIONS SOLELY AS A RESULT OF THEIR POSITIONS AS DIRECTORS, OFFICERS, OR EMPLOYEES OF THE MEMBER ORGANIZATIONS THAT OWN THE COMPANY. |
| Form 990, Part VI, Line 15 | THERE ARE NO EMPLOYEES COMPENSATED BY THE REPORTING ENTITY. THE PROCESS FOR DETERMINING THE COMPENSATION FOR THE FOLLOWING INDIVIDUAL'S COMPENSATION IS DISCLOSED ON THE MAIN LINE HEALTH SYSTEM (FORMERLY JHS) (EIN:23-2814503) FORM 990: KIRK E. GORMAN, AND R. CHRISTOPHER RAPHAELY. THE PROCESS FOR DETERMINING THE COMPENSATION FOR THE FOLLOWING INDIVIDUAL'S COMPENSATION IS DISCLOSED ON THE THOMAS JEFFERSON UNIVERSITY HOSPITAL (EIN:23-2829095) FORM 990: NEIL G. LUBARSKY, DAVID MCQUAID, JOHN EKARIUS, ALFRED C. SALVATO, KIRK GORMAN, AND BENJAMIN M. GERBER. THE PROCESS FOR DETERMINING THE COMPENSATION FOR THE FOLLOWING INDIVIDUAL'S COMPENSATION IS DISCLOSED ON THE MAIN LINE HOSPITALS, INC. (EIN:23-1352160) FORM 990: JOHN J. LYNCH III, MICHAEL J. BUONGIORNO AND BRIAN CORBETT. THE PROCESS FOR DETERMINING THE COMPENSATION FOR THE FOLLOWING INDIVIDUAL'S COMPENSATION IS DISCLOSED ON THE MAGEE REHABILITATION HOSPITAL (EIN:23-1476328) FORM 990: JACK A. CARROLL AND GUY W. FRIED. THE PROCESS FOR DETERMINING THE COMPENSATION FOR THE FOLLOWING INDIVIDUAL'S COMPENSATION IS DISCLOSED ON ARIA HEALTH (EIN:23-0596940) FORM 990: ANDREW DEVOE. |
| Form 990, Part VI, Line 3 Delegation of management duties | MARSH MANAGEMENT SERVICES, INC. IS A PROVIDER OF SPECIALIZED INSURANCE MANAGEMENT SERVICES TO THE CAPTIVE INSURANCE INDUSTRY. THE ORGANIZATION CONTRACTS WITH MARSH MANAGEMENT SERVICES, INC. TO RECEIVE SPECIALIZED INSURANCE ACCOUNTING AND MANAGEMENT SERVICES. |
| Form 990, Part VI, Line 6 Classes of members or stockholders | Members of the Corporation shall elect directors, each of whom shall hold office for a term of one year or until his or her successor is elected and qualified. Any director may resign at any time upon written notice to the Corporation. Subject to any limitations imposed by applicable law, the Board of Directors or any director may be removed from office at any time with or without cause by the affirmative vote of members holding not less than 75% of the outstanding Membership Units. Any newly created directorship or any vacancy occurring in the Board of Directors for any reason may be filled by a majority of the remaining members of the Board of Directors, although such majority is less than a quornm, and each director so elected shall hold office until the expiration of the term of office of the director whom he or she has replaced or until his or her successor is elected and qualified. |
| Form 990, Part VI, Line 7a Members or stockholders electing members of governing body | THE COMPANY'S COMMON MEMBER ELECTS THE BOARD BY MAJORITY VOTE OF MEMBERSHIP UNITS TO FILLS BOARD VACANCIES AND 75% OF MEMBERSHIP UNITS TO VOTE FOR THE REMOVAL OF DIRECTORS. |
| Form 990, Part VI, Line 11b Review of form 990 by governing body | FORM 990 IS SENT TO THE COMPANY'S AUDIT AND FINANCE COMMITTEE BEFORE IT IS SENT TO THE COMPANY'S BOARD OF DIRECTORS. The return is reviewed by the Audit and Finance Committee at one of its meetings. Subsequently, the Board reviews the Form 990 prior to its filing. |
| Form 990, Part VI, Line 12c Conflict of interest policy | THE LEGAL DEPARTMENT OF MAIN LINE HEALTH SYSTEM (FORMERLY JHS), ON BEHALF OF THE COMPANY, REGULARLY AND CONSISTENTLY MONITORS AND ENFORCES COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY. |
| Form 990, Part VI, Line 19 Required documents available to the public | THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. |
| Form 990, Part XI, Line 9 | OTHER CHANGES IN NET ASSETS REPRESENTS THE CHANGE IN EQUITY RESULTING FROM DIVIDEND PAYMENTS. |
| Form 990, Part XI, Line 9 Other changes in net assets or fund balances | DIVIDENDS AND RETURN OF CAPITAL DECLARED AND PAID - -41363924; |
| Form 990, Part XII, Line 2c Change of oversight process or selection process | THE ORGANIZATION HAS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF INDEPENDENT ACCOUNTANTS. |
| Core Form Part IV | Assistant Secretary, Marcy Waterfall, is an employee of Marsh Management Company, a captive management company. She does not receive compensation directly from Five Pointe Professional Liability Insurance Company or its related organizations. |
| Software ID: | 14000329 |
| Software Version: | 2014v1.0 |