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ron 990 Return of Organization Exempt From Income Tax 2 sss Under section 8%, 27, or 49470) afte intra Revenue Code oxcent prvateounasiony | 2014 ee Do not enter social security numbers on th fom a8 may be made publE. ‘naa Rowan Sec” > Information about Form 999 and its instructions is at wwm.ire.gow/tormas0. ‘For the 2044 calendar year, or tax year beginning 7 2044, and ending fe vane of rgaaaton HEALTH REPUBLIC INSURANCE OF Dena 8 oman ‘YORK, CORP. 45-3368051 BC] sactneee | Rabe ag See (PO Bact at ra dO EA ST Roonaan RE (momen |_30 BROAD STREET, 7TH FLOOR (212) 502-3062 Tones | Gaytown, se or rovn, Gay 2 or BEGH PORTS NEW YORK, NY_10004 6 crossreaws $__541,473, 01. FF tae ana acer a prnces once” DEBRA L PRTEDHAN Fa nasa re 30 BROAD STREET, FL. 7, NEW YORK, NY 10004 i) sorta rane Cne6 i tocsenpiaees [ [sone 1X [seu 2974 tneetoo | [sserenne | [ser {in tc aes oe tos J Wenste b> HTTPS?/ / NEWYORK, HEALTHREPOBLTC..US/ Hey row empire iromatonmasen [X [Coporien | [Tost] [sssocanon] [one > [krexottomaten 201 Im Ste otepasenicie WY ‘Summa 11 Bhefly describe the oranzaton's mation & mo agnivant saves TO PROVIDE NEW VORKERS WITH ACCESS TO, S02 1,1 530 GANNYOS 5 §] 2. ghost nace FL] tne osanzaon caceniet ts eproora of Spal wre an 2 tana oe 8| 3. Number of voting members of the governing body (Part Vi, ine 12) u ‘S| 4 Number of independent voting members of the governing body (Part VI, line 1b), id 8] 5 Ta numae of uwvos employes soa yor20' (Pot he, 7 2) 6 taal numer cf volcwes eae t neces a 8) 7a tat umes bomen ven in Perit ctainiCh we'd 7 3 pet vrs buna tabs use For 90. ne 3 3 | 8 connoutons and gras 21 Vi re 1, en 3 5 9 Program serwce revenue (Part Vill, line 2g) woes . ‘of 541,301, 961 2} 10 Investment income (Part Vill, column (A), tines 3, 4, and 7d), oe 29,728 171, 030. 144 oiner revenue (Part Vil, column (A), mes 5, 6d, 8, 8, 10e. and 116), we 0) 0 Saislcqe sodas tau i (ra ep Pest Van 1 SSeS ao ‘Grants and similar amounts pard (Part IX, cotumn (A), lines 1-3) oe eee | o mia of aT BIE, | Feldovaee Pen cnn ice 8) TBTGHSE, | 1622 728 i a 3 i “ 18, 667,531.| 119,563,726. Bsseaze:| ais Or SaTe ST es PEST a a 2/20 rota aseuts (Part x ne 16) | oo .. ..[36,850, 955. | 368, 480, 222) By ccoaere See eee 3B) 2 net nsencr lund rene Susana tan ine Bsr Les THO oT BERMI signature sioce Mee pec eae ee IR ST Oa EES SSRN SESS gi a ws neo lie le Pea Pe ee eee > <—f—-} ¢ ULL o, sion | D sacs Zz = wee |) Damier S thers Cfo rape a ew oar aml lay void |paUL. HAMERSCENIOT wa] [2eShees | por s9sve toe Ony [fimiscane PEDO USA, ELE Forsem b13-5501590. Tee G0 PARE AVENE, YORE, OY TOOT? eS Fay ihe IRS discuss th retvn win te preparer shown above” (ee stuns) For Fi LT ves [Tre work Reduction Act Notice, see the separale Instructions, Fem 980 Goi) acy eer de) ea GQ 3a —- HERLAW REPUBLIC INSURANCE OF 45-3368051 samo 2000 me 2 Slatement of Program Senice Accomplahments Check # Schedule © contains a response or note to any line mths Part i. . Oo 7 Brety desert the organzabor's mission 70 PROVIDE NeW YORKERS WITH ACCESS 10 AFFORDABLE NEALTHCARE AND A ‘oiee TW SHAPING THEIR NEALTH PLAN, WHILE DRIVING INNOVATION IN EVERYTHING WE DO 2 Did the organzation undertake any signficant program servces dung the year which were nat Isied on the rar Form 890 or 890-£27, 7 -.. Clves Ei] ne I'-¥es," describe these new services on Schedule © 3 Did the organization cease conducting, of make signticant changes in how st conducts, any program If¥es." descnbe these changes on Schedule O 4 Describe the organcatior’s program service accomplishments for each of its three largest program serves, as measured by expenses Section 50%(6)(3) and 501(c)(4) organzations are requred to report the amount of grants and allocations to others, the total expenses, and revenve, i any for each program servce reported aa (Code V(Epenses § Tneluding grants of )(Revenve & y HEALTH REPUBLIC _INSURANCE OF WEW YORK IS A NOT-FOR-PROFIT GEALTH INSURANCE CO-OP (CONSUMER OPERATED AND ORIENTED PLAN) ESTABLISHED ONDER THE AFFORDABLE CARE ACT 70 EXPAND AFFORDABLE HEALTHCARE QPTIONS FOR ALL NEW YORKERS. OUR HIGH-QUALITY PLANS ARE AVAILABLE ‘TO INDIVIDUALS AND SMALL GROUPS, BOTH ON EXCHANGE AND OFF, (ROUGHOUT_THE STATE. SINCE WE OPENED OUR DOORS IN OCTOBER OF 2013, WE'VE ENROLLED OVER 210,000 MEMBERS, MAKING US THE LARGEST HEALTH INSURANCE COOPERATIVE IN THE COUNTRY AND ONG OF THE FASTEST GROWING INSURANCE COMPANIES IN New YORK HISTORY. OUR TREMENDOUS SUCCESS IS A TESTAMENT 70 THE WAY OUR VALUES RESONATE WITH OUR MEMBERS. a Coie Viewers §, mcluding grants of § TiRevenue 5 7 We Cone. Tiexpenses § Tacluding grants of VRevenue 5 y “44 Other program services (Describe mn Schedule O) (Expenses § including grants of $ (Revenue § ) Je Total program sence openses Fam 980 Gore) 4-7.6F PAGE 2 117@ES 702V 11/12/2015 4:20:26 PMV : HEALTH REPUBLIC INSURANCE OF 45-3368051 om 900 201) em 3 Chackist of Required Schedules 1 ete xganaaon desc n secon #0102) o 487) (te han a pate fundahn? 2 Sovogarente exes const Shildon em tector | coe 4 Sttvonsoie9) remus bee specaion neg by Sve ohn chon sh Strton mele dm te yea” Iencconso Sole @ Porth ap 5 Shwe agontton osetonS30(0) SGT, or 20TeNE eens lene teh Bek Pena fel |x “Yn-comlee Suse Pot | |e te cmoenen nanee on owe rn srw Yexconse Sowa Pot if fk cere lone tte Le Te Seuneqneton oman) 'ee-crgls Sane Pot fof |e tera orton ae enol sce gees nt ine acon Sate er ” fuel [ {© Did the organization report an amount for other lisbilties in Part X, ine 257 if"Yes, “complete Schedule D, Pan x’ [146] x 01d the organization's seperate or consolidated financal statements forthe tax year molude @ footnote that cesses the ecganzation’ abit for uncertan tx pesitons uncer FIN 48 (ASC 740)? I "Yes “complete Schedule D, Part X [ae x 128 Did the organzation obtain separate, independent audited financial statements for the tax year? if "Yes, ‘complete Schedule D, Parts XIand il... . [42a] x 1b Was the organization neluded in congolsied, widependent audied fnancal statements forthe tax year? if "es and the erganzaton ensnered "No" fo line 128, then completng Schedule O, Pats XIandXIls optional... vw... + «= « (420) x 413. Ie the organizaton a echool desenbed in section 170(0)(1)A)a)? If*¥es," complete Schedule E. fies. [as x ‘a id the organization mannan an office, employees, or agents outsde ofthe Unted States? |... sss... 4a. x 'b Did the organzaton have aggregate revenues or expenses of more than $10,000 from grantmakies, fundraising, business, investment, and program servece actives outside the United States, or aggregate foreign investments valued at $100,000 or more? if "Yes,"complete Schedule F, Parts land IV... . . e{rae| | x 418 Did the oxganzation report on Part X, column (A) ne 3, more than $5,000 of grants or other assistance to oF for any foregn organizaton? If Yes,"complete Schedule F Pats i and IV . [8 x 16 Dd the organization report on Part iX. column (A) ine 3, more than $5,000 of aggregate grants or other assistance to oF for foreign dividuals? If"Yes," complete Schedule F,Parts Wand V .. .. oe. eee ev wea 46 x 47 Did the organization repor a total of more than $15,000 of expenses for professional fundraising serwces on Part IX, column (A), ines 6 and 116? If"Yes,"complete Schedule G, Part (see instructions) [a7 x 18 Did the organwzaton report more than $15,000 total of fundrarsing event gross income and contributions on Part Vil, ines 1 and 8a” IfYos, "complete Schedule G, Part. cece eeeeeeteceerecenes 18 x 418 Did the organization report more than $15,000 of gross income from gaming activites on Part Vil, ine 9a? if"¥es."complete Schedule G,Part ll... ss. ve ee jan x 20a Dad the organization operate one or more hosptal cites? W "Yes." compieto Schedule H | : 20a x 1b if"¥es" to ine 208, did the organzation attach a copy of Is audited fmancial statements to ths return? || | | | [20m a Fam 980 ora) ai7eBs 702v 11/12/2015 4:20:26 PMV 14-7.6F PAGE 3 HEALTH REPUBLIC INSURANCE OF 45-3368051 00042014) a 2 2 2a 26 a 2 2 0 4 2 2 388 Py ” ae 192 Note, All Form 990 ters are tequved to complete Schedule (Checklist of Required Schedules (contnued) Did the organzation report more than $5,000 of grants or other assistance to any domestc organization or ‘domestic government on Part IX, column (A), ine 1? If "Yee," complete Schedule, Parts and I Did the organzation report more than $5,000 of grants or other assistance to of for domestic indnnduals on PartiX, column (A), ine 2? 1f "Yes," complete Schedule | Parts and I. . id the organization answer "Yes" to Part Vi, Section A. ine 3, 4, or 5 about compensation of the ‘organization's current and former officers, directors, trustees, key employees, and highest compensated ‘employees? If"Yes,"complete Schedule J . Did the organzation have a taxexempi band rssue with an outstanding ‘principal amount of more than $100,000 as of the last day of the year. that was issued after December 31, 20027 if "Yes, through 24d and complete Schedule K If'No,"go tone 25a. co id the organzaton invest any proceeds of tax-exempt bonds beyond a temporary period exception?. . -. - Did the organzation maintain an escrow account other than a refunding escrow at any time during the year to defease any tax-exempt bonds? . es Did the organzation act as an “on behalf of issuer for bonds outstanding at any ime dunng the year? ‘Section £01(c)(3), 601(c){4), and 601(c)(28) organizations. Did the organization engage in an excess benefit transaction with a disqualfied person dunng the year? IfYes," complete Schedule L, Part]... « 's the organization aware that engaged in an excass benefit transaction with a disqualifed person in a pror Yeu, nd ta ne wareacion fa 91 been reported on any ofthe crpanzatons por Fome 90 or S902? I1"¥es," complete Schedule L, Part | : Dd the organzation report any amount on Part X, line 5, 6, oF 22 for recewables from or payables to any current oF former officers, directors, trustees, key employees, highest compensated employees, or ‘isqualiied persons? If "Yes," complete Schedule L, Part i! Did the organization provde a grant of other assistance 10 ‘an officer, director, tustoe, key employee, substantial contebutor or employee thereof, @ grant selection committee member, or to a 35% contolled entity oF family member of any of these persons? If "Yes" complete Schedule L, Pati ‘Was the organzation @ party to a busness transaction with one of the following partes (eee Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions) Accurrent or former officer, director trustee, orkey employee? If"Yes," complete Schedule L, Part IV - ‘A family member of a current or former officer, director. trustee, of key employee? if "Yes complete ‘Schedule L, Part IV : ‘An entity of which a current of former oficer, director, trustee, or Key employee (or a farmly member thereof) ‘was an officer, director, trustee, or director indirect owner? If "Yoscomplete Schedule L, Pat Iv 24 x 2 x 4b aoe 24g 250 x 25 x ar x 2ta x 2» x 200 x Did the organization recewe more than $25,000 n non-cash contrbutions? If "Yes," complete Schedule M. . 29 x Did the organization recewve contnbutions of ar, historcal treasures, or other similar assets, or qualiied conservation contributions? If "Yes," complete Schedule M 30 x Did the organzation iqudate, terminate, or dissolve and cease operations? If "Yes" complete Schedule N, pale ee Did the organzation sel, exchange, spose of, of transfer more than 25% of is net assets? if "Yes" complete Schedule N, Parti 2 x Did the organzaton own 100% of an enity disregarded as separate from the organzation under Regulations sections 301 7701-2 and 301.7701-37 I"Yes,"complete Schedule R, Part... - 33 x ‘Was the organization related to any tax-exempt or taxable entity? If “Yes” complete Schedule R. Parti OrlV, and Part V,lne 1. 3a x Did the organzation have a controfed entity wihin the mearing of section 512(0X 13)? 358 x I "Yes" to line 36a, did the organization recene any payment from or engage in’any transaction wih & controlled entity within the meaning of secton 512(b)(13)? If "Yes," complete Schedule R, Part V, ne 2 35 Section 601(c)(3) organizations. Did the organization make any transfers to an exempt non-chartable related organzaton? If"Yes,"complote Schedule R, Part V, ine 2 . 36 Did the organization conduct more than 5% of is actiwties through an entiy that ws not a related organization and that is treated as a partnership for federal ncome tax purposes? "Yes," complete Schedule R, Part Vi. a7 x Did the organization complete Schedule O and provide explanations in Schedule O for Part Vi ines 11 and ae] x Jo2v 11/12/2015 4:20:26 PMV 14-7.6F Fem 990 Zora) PAGE 4 HEALTH REPUBLIC INSURANCE OF 45-3368051 orm 960 (2014) ‘Statements Regarding Other IRS Filings and Tax Compliance Check if Schedule O contains a response or note to any line mn this Part V . . eae 5 1 emertne under epontedin Box3 of For 1086 Enter-0 ot appoabe, [ae b Enter the number of Forms W-2G included in line 1a Enter -0- rf not applicable... 4b {bale organeaton eampy wih bocup winters for repotalepepsnis Te wanda ard fapotebe gumig (genbin)vnnngs pean? | Ae 2a Emre rumour of employers roped on Ferm W3.Tivanital ot Wage and Tax = rrrr—“—s—OCSCOCOCOCNO_OCOCOCOC*OC*OCsitistiétét_N b fr atleast one epured’on tne Za, the rgeneaton Tis al requed feet! employmen axes? [20 |B fanit te som aftnes taand Ze teawrfnan 760 yoorayterequredio ee oeimanccoot) i sa bale ogenaniontave uncles tanese gessincome of 81,000 ormarecurmye yea? vn... [aaf Px 3 von nent tea For 6D‘ ns yeu? Nfl rondo an enptonnanm Schade O ey oo rrFrt~——=—S~—i‘<‘CSCOC™C*ststsCtsC*CN# nee al |x bi ven” entre nah einen : Ses nstuctone fo fing reguroments for FACEN Form Vid) Repar l Fveign Buk ond Praca! Recoons af pa i sa (ace he orgenzaton apart 1 prohibied tx she vansacton at any tre dung the axe? re ¢ ttover tome Sar Sb athe ergerzoton tie Fom 288.77 fe FS rrt—~—“™—si—OOOCONONCOCOCOisCCisCCziCisSC=sCsaizasé’s‘iCON b f'n" ad he srgencaton mode on evry tebtaton wn ween esoment et beh enirbulans of ots mere notte deaucb? : a 7 Organizations that may receive deductible ‘contributions unde ‘section 1704¢). Y ba ie orurantonrcrow ¢bayment m excant of $78 made pty oe connie and party fr goods tnd sareonsponiedie te peer? ne i tress ae he ooncatan ety he donor al thé aus af he goa sears prowied | 2 Sha tne pananton son schege, or iherwen dopeee of gale Powral Peper er wash wes LD ope Persone omen te 4 If "Yes." indicate the number of Forms 6282 fied durng the year»... ss... Uta L I rr——r—C‘)EN)N"N"R9 ¢ paltneotnaaton ngs yar pty pemume arecy or arecy an apereonabonetcrwec nn [ Fine oponane cede sewouie o Cuaed munsasd rope oir epson he fom st00 awed [TA A tensupmaaorseanesscrwoctor acu ou onsoen ero woe, eae opm ina Fom see [TR 2” Sooneuing ergunzatone maintaining donor advo fund. De 2 donor ewacd fond mantaned by he [zt =[—I sporcregorgenason fav aces booren Tenge storytmeaurmpe yr? ns a 9. Spomaritg sgeatatons mevaiing dont wee nan Ht 1 bul tetponeoing crguraston mae oy wrablo avons unde seton 4867 eee fa $ une sporaueg owenanlon make @anrounon loa dra doreredvex ripe? a 40” Secton 010) erarzatons Er 's inion eat tedcapal corevton mead on Pan VL Ww 12 =e 102 ‘ er r——<—=—rzs—SCi‘CNCSNCi‘iCzisSaKCazstS. : 11° Sector sete) ornate, Ener 1a «Crone neome om member or abrenoes tte ye $ Gow moma fom cher touces fe nol hat noais'dve'& pad 1 ior sowese . a =—=C—srstse 1 | a Lrt—~—~—sOr—OOCOSOSONCCOCCisCCSCSCNCiCiCiSsC'¥O Total (add lines tb and te). >» % Total number of ndivdusls (mcluding bat not med to those sted above) who received more than $100,000 of reportable compensation from the organzation 1 [Yes] No 3 Did the organzation lst any former officer, duector, or trustee, key employee, or highest compensated ‘employee on ine 12? "Yes," complete Schedule J for such indwdual . ee cee x 4 For any individual Isted on line 1a, 1 the sum of reportable compensation and other compensation from the tf Stgenaton and related organatons. greater than $160,000" If "Yes" comple Schedule for sich ngivndual. 4 | x 5 Did any person isted on line 1a recene or accrue compensaton from any unrelated organcaton or mdivdvei i for serwces rendered o the organization? If"Yes "complete Schedule Jfor such person. . a. Is x ‘Séztion B. Independent Contractors 1 Complete this table for your five highest compensated independent contractors that recewed more than $100,000 of Compensation from the organization Report compensaten for the calendar year ending with of within the organization's tax year « @ ©, Name and business adress Description of serwces Compensation 2 Total number of independent coniraciors (iicluding bul not Imnited to those Isted above) who recewed ‘more than $100,000 in compensation from the organization > Fom 990 (2014) LIES 7O2V 11/12/2015 4:20:26 PMV 14-7.6F PAGE 9 orm 0602014) _ FEMAMI Statement of Revenue (Check Schedule O contains a response or note to any tne in ths Part Vil HEALTH REPUBLIC INSURANCE OF 4573368051 eae 9 nit, Geant ? : i Federated campagne « rn Mombershupdues.. ..-... « « [10 Fundraising events 46 Relaedorgmaaions ..-...- « [1d Government grants (cortnbutensy. [48 Noncasn cotnbutens neue nies tt & Total Adg ines $e: Program service Revenue er sama {other propram servoe revenue Total Ads lines 20:21 Other Revenue Investment income (meluding dividends, and othe sma amounts). Income tr investment of tascexemet bond Royates « Rea Cross ens « Less rental expenses Rental ncame oss) = Net rental income or (los {Gross aroun rom aie of [ 0) Secures assets olterthaninventory Less cost or oer bass, and ses epenses «5. - Gam or (oes) « Net gan 0: (loos) - Gross ingame ftom fundraising events (not nctug § of contributions reported on ine 16) See PartlV, tne 18 Less aect expenses « Not mcome oF (oss) Wom fundatsing evens Cross income trom gaming aetuties ‘See PatW,lne 19 Less arectemponses «2 « S Net income oF (xs) fom gaming activites Gross ses of snventoy, eas returns and allowances. - Less cost of goods sold. = Netincome oF (los) orn ces of vest al a 0 tsa Mscelianeovs Revenue ‘Al other revenue ae Total Adciines 118-114 - « Total covenve, Seo mstuctons LITSES 702V 11/12/2015 4:20:26 PM Fom990 (2014) PAGE 10 Form 990 2014) HEALTH REPUBLIC INSURANCE OF 4523368051 ome 10 ‘Statement of Functional Expenses Section 507()(9) and 801(0(4) organations musi complete al coumns Al bir organaatons mat compe colurn (A) ‘Check i Schedule © contains a response or note to any ine mths PanX ee Te] ‘Do not include amounts reported on lines 6b, 7b,| a; ¢aperses Progr serace Manag Sere and Funcrasing 8, 9b, and 100 of Part Vit. cin Somer t cca ‘en domeste gourmets Soe PAW. tne?" «= 2 Gaants and other assstance to domestic mcviduals See Part W, br 22. 3. Gres and cher asustance to foreign ‘ofgantzatons oregn government, and foreign tnciwauale See Part V, Ines 15 and 16 4 Benet paid too for members , 407,025,926. 5 Compensaten of current officers, directors trate ondieyarpiones ss 1,974,706, pent ete a sen AA) and peri dro! a ec E81, 17 Ober carer end woot, TEA 2: Penson lan sce an constant fect 04) and 4030) employer contro) 52,020, 2 Oter employe tenets 369,535. 10 Powctines sn 703,145 11 Fest aeuces campo) + Management D teoe 1 5or 75a c Accoring 63, 819 atone * pronase in Pi ‘tovemantmanagenenies = 9 Ot eine np ene mn 04 rcs totem inti apoerenaro) 10,010,533, 42. Aneing on romance 1,850,105. 43. Oftremenes «= 4339,037 44 tomato wenclogy. 1062, 6871 1 Royse 18 Occuponoy Taw, 7 Taw... see oe 162,020 2 paymnts ot vavel ota exgaase {erry tel st ta pubic eons 19 Conferences converts end meng TET, mete 21 Payments ouiaan. =| 22 Dorecatn,dpleton snd aeios Ta 505, 23° Insurance . bene eee 104,333, 24 on epi onat sown nt cont Sow ie mace apes ie 3te Gt ent ow dus arson Bae 0} CHARIS. ADUUSTUCNT DLEDISES. 35,228, 16,671,098 35,597,093. SBROER cOMIESSIONS 3,348,593. » Aloter omens — 75,104,333 28” tm hnctond epee fad ms | age a [619,012,381 Si Mint cosa Compe hg ine cape Spenanion peed elit) teats tinrrsng savctavon Checxhee LW {slong SOP 882 (Ae 98-720). Tease Fam BO aH 117858 702V 11/12/2015 4:20:26 PMV 14-7.6 PAGE 12 ABALTH REPUBLIC INSURANCE OF 45-3368051 Fem ot 2014) met ‘Balance Sheet ‘Check if Schedule O contains @ response or note to any line in this Part X 2-1 I « ® epning ofyee Endy 7 Gash = nomnerestbeanng 4,080,046] 4 | 7,133,365 2 Savngs and temporary cash estnenis, | a:a51-7144] 2 | e,1s2,214 2. Pledges and grants recenabie, nat a 5 4 Accounts recenable, cat. 216707, 370 5 Loone and other reconabis from curéni and former aficers, vector, trustees, key. employees, and hghest compensated employees, Compete Partiiof Schedule L 5 ° 66 Coomand tnt recewates om oti dtd Siac ctined und’ sac ‘Ssuin pons desrbes 9 cian saG8(C\ONe), anu contiocing crore ane sardate igomaaions of sacicn S01(C) runny employees Senet | - |. 1o| Stouts ic ntcton) Campow Pott Sea. é ° 8] 1 Notes and loans recewale, net 7 [38,281,565 3) & tmvertonesforsaieoruse 2 3 4 Prepaid expenses and deferred charges 2 3 10a Lang, budings. and equpment cost or other bass Compute Pant Vict Schedle D {108 401, 320. : b Less accumusted deprcaton......-. .. [10b a,3i2~ 30,976.|106 352,468. 11" Imvoutmente-pubboy ides sacunies 7. 44574, 666.] 411. | 117,956,207 12 Investments ~ other secures See Part, ne 14 12 3 13. Investments - programvelated See Part IV, ne 11> 13 3 a 44 Z 18 Other assets Seo Pati, ine 14 3esra Las | 779 057,055 16 Tota asots_ Add Ines 1 trough 15 (msi equal ine 34 36,850. 955.}46 | 368480. 207 17 Accounts payable and acctued expenses, 1/859,038[47 | _32:183,230- 48 Grants poyabie 48 3 18 Doterred reverse 272” F651 003. [a9 | 37100, 050 20 Taxcesempt bond habines 20 3 {21 Eecrow or custodial account lability Complete Pan ot Scheie |” 21 3 3}z2 Loans and other payables to curren and former officers, director 3 trustees, key employees, highest compensated employees, and Lo Gisaualfed persons Complete Parti of Schedule L. 2 8 23. Secured mortgages and notes payable fo unelted td partes 23 3 24 Unsecured notes and loans payable to unrelated thd parties, FE, 550, abo. 24 | P3103, 800. 25. Other tables {inclcing federal income tax payables to ‘ested thea partes, and other lables not included on ines 17-24) Compete Part X tf Schedule D 5,220,702. a6 | 212,342,485. 26 Total liblties, Aad ines 17 tnvough 25 = L 35, 709,583.[26 | 304-739,545) ‘Organizations that follow SFAS 117 (ASG 868), check here ® land | Somplote ties 27 through 29, and tines 93 and 9a . a E]27 Unvesintednetassets a )28 Temporary resineted net assets ra 329 Permanent retried et aces, 28 BF” crsanzatone tat do not flow SFAS 117 (ASC 880) hackers LZ] ane | comin tines 30 trough se 42]30 Copia stock or tust panel. or current funds. 20 o 3] 31 Padi or captalsurphis or land, butting, or equpmantiund |” | FA 3 2/32 Retained earnings, endowment, accumulated income, or other funds 25,141,572. 32 | __63,740, 677. 3/52 Totainetascotsoctnd balances 33,141,579. 33 | —63.740..677 4 _Totallabites and net assetafund batons 36,850, 955.[34[ 368.480. 222 Fem 990 2016) 1178S 702V 11/12/2015 4:20:26 PMV 14-7.6F PAGE 12 HEALTH REPUBLIC INSURANCE OF 45-3368051 om 9502014) Reconciliation of Net Assets Check if Schedule 0 contains a response or note to any line in thes Part Xi Page 12 ma Sai, 473, 011 {Total revenue (must equal Part VI, column (A), ine 12) . . : i 2. Total expenses (must equal Part IX, column (A), ne 25) [2 [619,022,367 3 Revenue less expenses Subtract Ine 2 from ine +. 3 77,539,370, {4 Net assets of fund balances at beginning of year (must equal Par X, ine 33, column Al)» 4 23,141,572. 5 Net unrealized game (losses) on investments, 5 6 6 Donated eervces and use of facies 6 0 7° avestment expenses . : 7 0 8 Por penod adjustments» oss... : 8 0 9 Other changes in net assets or fund balances (explannn Schedule 0) 2 | 118,138,475. 40 Net asseis of fund balances at end of year Combine ines 3 through ® (must owe Part X. tine cs cohomn (0) eset ree creer : so] 63,740,677. Financial Statements and Reporting Check if Schedule O contans a response or note to any line in this Part Xi wl Yes | No 1 Accounting method used to prepare the Form 990 [_] Cash Accrual [_] Other HW the organization changed its method of accounting from a prior year or checked “Other” explain Schedule O 2a Were the organization's fmancial statements compiled or reviewed by an independent accountant? 2a x It "es." check a box below to indicate whether the fnancal statements for the year were compiled or reviewed on a separate basis. consoldated basis, or both Ci separate bass — L_] Consolated bass [_} Both consolidated and separate basis b Were the organization’ financial statements audited by an independent accountant? - 2p {x th"¥es," check a box below to indicate whether the financial statements for the year were audi separate basse, consobdated bass, or both Separate bass _] Consolidated bass [] Both consolidated and separate bass l1¥es" to line 2a oF 2b, does the organization have a commitiee that assumes responsibity for oversight of the aucit,rewew, or compilation ofits financial statements and selection of an independent accountant? | 26 | X. I the organization changed either ts oversight process or selection process during the tax year, explain in Schedule © 3a As a result of a federal award, was the organization requred to undergo an audit or audits as set forth in the Single Audit Act and OMB Cirular A-1337 3a |x bb it'¥es" did the organzatan undergo the requred aud or audts? ifthe organization did not undergo the required audit or audits, explain why In Schedule O and descnbe any steps taken to undergo such audits ap | x 1178ES 702V 11/12/2015 4:20:26 PMV 14-7.6F Fem 990 (2014) PAGE 13, SCHEDULE D (Form 390) Supplemental Financial Statements Cee Usb Seer > Complete i the organization answered "Yes" to Form 990, Party, line 6, 7,8, 9, 10,118, 4b, He, 14, He, 1, 12a, oF 125. > Attach to Form 990 Depanment tne Teesy [onal fewave Sees” | _ be Information about Schedule 0 (Form $80) ands metuetions ie at wwwirs.gowforms00. ame of organaatonEALTA REPUBLIC INSURANCE OF ‘Employer aeenbon number NEW YORK, CORP. 45-3368051 ‘Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organwation answered "Yes" to Form 990, Part IV, line 6 (2) Donor advised fund 1) Funds and othr some Total number at end of year. ‘Aggregate value of contnbutions to (during year) ‘Aggregate value of grants from (dunng yess) ‘Aggregate value at end of ye Did the organization inform all donors and donor adveore in writing that the assels held in donor advised funds are the organization's property, subject to the organization's exclusive legal contro’? ........... L_Jves (]no 6 Did the organzation inform all grantees, donors, and donor adusors in writing that grant funds can be used ‘only for chartable purposes and not for the benefit of the donor or denor advisor, oF for any other purpose confernng impermissible private benef? =. AAAAnABAnS Clves Fo ‘Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7 7 Purpose(s) of conservation easements held by the orgaration (check all that apply) Preservation of land for publi use (e g , recreation or educaton) Preservation of a historically important and area Protecton of natural habtat Preservaton of a certified histone structure Preservation of open space 2 Complete ines 2a through 2d i the organization held a qualified conservation contribution in the form of a conservation feacement on the last day ofthe tax year Ai af Hold at the End of the Tax Year ‘4 Total number of conservation easements... . . 28 Total acreage restricted by conservation easements... 2b © Number of conservation easements on a certhed histone sructure cluded in(@) 4 Number of conservation easements included in (c) acqured after 8/17/08, and not on @ histone structure listed in the National Register 20 3. Number of conservation easements modified, iansfered, released, extinguished, oF terminated By the organization dunng the: taxyear 4 Number of states where property subject to conservation easement is located 5 Does the organization have a written polcy regarding the periodic monitoring, inspection, handing of volations, and enforcement of the conservaton easements it holds? Ove One 6 Staff and volunteer hours devoted to monitorng. inspecting, and enforcing conservation easements dunng the year > 7 Amount of expenses incuréed In montlonng, nspectng, and enforcing conservation easements during the year bs 18 Does each conservation easement reported on ine 2{¢) above satisfy the requrements of secton 170(t)(4N8)() and section 170(4NEN? ee eee eee eee eee eee eee eee Dyer One & In Part ill, 6escnbe how the organization reports conservation easements ints revenve and expense statement, and balance sheet, and include, f applicable, the lex of the footnote to the organization's financial statements that describes the erganovar's accouring lor cotecaton essere [EET Organizations Maintaining Collections of An, Historical Treasures, or Other Similar Assots Complete i the organaven answered “Yes” to Form 990, Part Vine 8 7 ihe spanner, eared as pete unser SFAS 138 (ASC B86), vt fo report ravenna nd le sey works ‘oF art histoncal treasufee, or other. similar assets held for pubhe exnion, education, of research i furtherance. of ube servos, provi, in Part Xil the tex of ihe footnote to ts financial statements thal Gescrbes these tems If the organzation elected, as permited under SFAS 116 (ASC 958), to report in sts revenue statement and balance shest ‘works of art, histoncal treasures, of other simiar assets held for puble exhibion, education, or research in furtherance of public sermoe, provise the following amounts relating to these ems () Revenue included in Form 980, Part Vil, ne 1 . (i) Assets included in Form 990, Pant X. 2. tthe organzation recened or held works of at, histoncal treasures, of other simiar assets for francial gain, provde the folowng amounts requredt be epoed under SFAS 116 (ASC 858) reltng fo these fame ‘9 Revenue mclided in Form 990, Part Vil, ine 1 b_Assets included m Form 990, Part X. For Paperwork Reduction Act Natce, ms. ms ee the instructions for Form 90. Benedule B arm 0) 200 TT7ees 7o2v 11/12/2015 0:26 PMV 14-7.66 PAGE 14 : HEALTH REPUBLIC INSURANCE OF 45-3368081 sche 0 Fam 90) 2014 22 ‘Organizations Waintalning Collections of Art, Historical Treasures, or Other Similar Assels (Continued 3. Usw the organzators scquiston, accesson, and ober records, check any ofthe folowng that are @sgicant use offs allan ems (check that opp) Publ etibton 4 [F] Loan or exchange programs Scholarly research © TD omer ©] Preseraton for hture generations 4° Browse a desenpton ofthe erganaters colections and explain how they futher the organzation's exempt purpose in Pan xu 5 Dur the year dl he organization sot or reave donations of af, orl trance, ootar smdar soso tobe sok to rae und rata nan fo be nantaned aspartate oganzaonscolecion?”-... ["1¥es [1 Wo Escrow and Custodial Arrangements. Complete the organzaton answered Yes" to Form 990, Part, ine 8. or reported an amount on Form 980, Part Xine 24 ‘1a. Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not included on Form 990, Part X? fe - Dives () no bb ifY¥es." explain the arrangement in Part Xill and complete the following table ‘Amount © Begining balance 2... eee cece ee eee eee eee eee es [te @ Additons dunng the year sss sss 44 Distributions dunng the year else Ending balance af 2a_ Did the organization include an amount on Form 960, Par X, ine 21, for escrow or custodial account labuiy? Ove Ly b_ifYes.” explain the arrangement n Part Xl Check here the explanation has been provded in Part XI Endowment Funds. Complete ithe organzaion answered "Yes" to Form 990, Part IV, ine 10" Carew |) Preyer] (Too yea 1) Te ea | Tl Fou as Dok 4a Beginning of year balance. , b Contrbutons Net investment earings, gans, land losses, 1d. Grants or scholarships : @ Other expenditures for facies and programs... 0.2... 1 Adminstrative expenses | || | 19 End of year balance, 2° Provide the estimated percentage ofthe current year end balance (ine 1g, column (a)) held as 2 Board designated or quas-endowment % b Permanent endowment * © Temporanty restricted end: ‘The percentages inlnes 22, 2b, and 26 haul Gal 100% 3a. Are there endowment funds not in the possession ofthe organtzation that are held and adminstered forthe ‘organzaton by () unvelated organzatons , {related organzatons bb IfYes" to 3a(y), are the ieiated organcations lated as requred on Schedule 4 Describe in Part Xill the mended uses of the organization's endowment funds Tand, Buildings, and Equipment. Complete i the organiaton answered "Yes" to Form 990, Part IV line 11a See Form 990, Part X, ine 10, Deserpton ope ews stabs | ()Cosigaprbare | (6) Aceumaee (ai Book aoe Ta Land b Buildings | © Leasehold improvements, 4 Equipment . 701,320, 38,532 352, 408 2 Other A ARBAARA AAR Total Add ines Ta though Te (Column (d) must equal Form 980, Part X column (B)_ ne 10(6)) el 352,408. 1179S 702V 11/12/2015 4:20:26 PMV 14-7.6F PAGE 15 . HEALTH REPUBLIC INSURANCE. OF 45-3368051 scmsule 0 For 50204 pan investments - Other Securities. Gomplete ithe organzation answered "Yes" to Form 990, Part Vine 11b See Form 990, PartX, tine 12 w Detenpon f scary er carey Book aie {e Mathod of valuavon tna sane eco) cos Sat yar aoe G)Financaldervawes ..... (2) Closely-held equty mterests eat Cola 5) ss eas Fa 586 Poa (ine V2) EXERUI investments - Program Related. Complete ifthe organization answered "Yes" to Form 990, Part IV, Ine 11¢ See Form 990, Part X, Ine 13. (@) Desorption of wesimont (@) Book vaue (Method of vauon| Coster endoyear market value “a. (osu yt oun For 980, Pua ce Ve FH) E ‘Other Assets. Complete if the organization answered "Yes" to Form 990, Part IV. line 11d. See Form $60, Part X. line 15. w)Descagon (Bost ave (HACCRUED RETROSPECTIVE PREMIONS (@)_= ACA RISK CORRIDOR 715, 500, 000 (Q)AMOINTS RECOVERABLE FROW (a) REINSURERS SE OT (UNCOLLECTED PRERTOMS 32129, 209 (ACCRUED INT. INC. RECEIVABLE 305,774 @ © 2 otal. (Colin (o) must equal Form 990 Pan Xe ine 75) STs ‘Other Liabilities. Complete i he organization answered "Yes" to Form 990, Part IV, ine 11¢ or 1if See Form 990, Part X. tine 25 Hi a Deacon aay a Tone TI i) Federalncome tres (CLAIMS UNPAID Tiga] < al (RISK ADJUSTMENT PAYABLE 43, 851,030, | (4)PREMIUM DEFICIENCY RESERVE 21, 900, 000. . : ‘|| (@)CEDED RBTNSURANCS_PREWTUNS PAY. 4345, 971, : (QUNPAID CLAIMS ADJUSTMENT ERPS 2,859,005, ©, : | ®) | . | @ i | y Tat (tana By must aul Fam 090 Par cal ine 75) | 212, 342, AS | 2. Libiity fer uncertan tax postions In Pat Xl, prose the txt ofthe footnote to the ergarzatiosfinancal statements that reports the Ciganizaton's hay fr uncertan tax postions under FIN 48 (ASC 740) Check here the text ofthe footnote has been prowaed im Part xi [—] iizv + 000 “Sehedule 0 (Form 980) 2014 TTraes 7o2v 11/12/2015 4:20:26 PM Vv 14-7.6F PAGE 16 HEALTH REPUBLIC INSURANCE OF 45-3369081 sexes 0 em 90) 2014 rage Reconciliation of Revenue per Audiied Financial Statemonis With Revenue per Return. Complete f the organwation answered "Yes" to Form 980, Part V, ine 12a 7 “Total revenve, gains, and other support per audied francel statements 2 Amounts cluded on tne 1 but not on Form 890, Part Vil ine 12 Net uncealzed gains (losses) on vestments, Donated services and use offacites Recovenes of por year grants Otter (Deserve m Pan Xi!) , ‘Ad ines 28 through 26... 3 Subtract ine 2e fom ine't ‘Amounts inekided on Form 990, Part Vl ne 12. but not on ine 1 Investment expenses not included on Ferm 980. Part Vl ine 7b, . Otter (Deserbe in Part Xl) © Addines 4a and 4b, = ae 5 Total revenue Add nas 3 and 4. (This must equel Form 390. Parti ine 12) s | 540,875,081. Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organizaton answered "Yes" to Form 880, Part V. line 12a 1 Total expenses and losses per audited nancal statements 2 Amounts included on Ine 1 But not on Form 960, Part IX ie 25 1) sas or 3 | $47,073, 07 1 eis, 032, 3 ‘2 Donated servees and use of faites. 2 > Pror year adjustments 2b © Otherlosses. eae 26 @ Other (Descitiin Maa tj 7 26 f@ Add ines 28 through 24, a 3° Subtract ine 2e from ine ae 3 | 619, 012,58 4 Amounts included on Form 980, Part iX ine 25, but not on inet Investment expenses not mcluded on Form 990, Part Vil ine 75 as b Other (DescroemnPartxil) ab © Add tines 42 and 4b eee 5 Total expenses Add tnés'S" sind de! (Thus must adult Fai 908, Pari tind 16). EATEM supplemental information. Provide the descrplions requied for Part ll, ines 3, 5, and 9, Part Il, ines Ta and 4 Part, Ines Tb and 2b, Pan V.ine 4, Pan X Ine 2, Part XI, ines 2d and 4, and Part XIl, nes 24 and 4b. Also complete ths part to provide any additonal mormaton 5 | 619,019, 301. = Teheduia 6 Fam 990/204 1176ES 702V 11/12/2015 4:20:26 PMV 14-7.6F PAGE 17 scree 0 rom 00)204 HEALTH REPUBLIC INSURANCE OF 45-3360051 pages Supplomontal information (Continued) ‘Senedule B Form 60) 7098 A17BES 702V 11/12/2015 4:20:26 PMV 14-7.6F PAGE 18 SCHEDULE J Compensation Information oe io 15460067 (Form 990) For conan ers, Diet, Tune, ey Enpyes and gh cmpenested on > complete he orsanaton answered “Yes” on Frm #80, Pat Ww aperiment et me Trsury eee ® Attach to Form 990 ee Re Srerraccnetne”” | _» tnfoomation about Schedule J For S80) and Re mstzueons sat wis gov/orm900. pene eve ogswaah HEALTH REPUBLIC INSURAN: Enns Taner ae NER YORK, CORP 45-3369051 ‘Questions Regarding Compensation 41a Check the appropriate boxes) if the organtzation provided any ofthe following to or for aperson sted in Form 1990, Pan Vil Section Aline 18 Complete Part Il to provide any relevant information regarding these items First-class or charter travel Housing allowance or residence for personal use ‘Travel for companons Payments for business use of personal residence ‘Tax indemnification and gross-up payments Health or social club dues or mttation fees Discretionary spending account Personal services (eg , max, chauffeur, chef) I any ofthe bores on Ine 18 ae checked dd the organiaton follow a wniten poley regaréag payment exfembursemen or prowston of al of the expensee descrbed above” if "No, complet Part ewpian. 2 Did the organization ‘require subsiantiaton prior to rermbursing or allowing expenses incurred by all Seco, vues, and fice, clung the CEOVEsacine Orato, regarding the tame checked m ne we. 3 Indicate whch, any ofthe folowng the fing organization used to establish the compensation of the organizaton’s CEO/Executive Director Check all that apply Do not check any boxes for methods used by a felated organization fo establish compensation of the CEO/Executve Director, but plan m Par Il %%] Compensation committee Written employment contract X] independent compensation consultant 3%] Compensation survey or study X] Form 990 of other organzations x] Approval by the board or compensation committee » 4. During the year, did any person listed m Form 990, Part Vl, Section A ine ta, with respect tothe fing organization ofa related organzaton . Recewe a severance payment or change-cf-contral payment”... : 4a Paricpate in, or recewve payment from, a supplemental nongualfied retrement plan”. © Partiepate in. oF receive payment from, an equty-based compensation arrangement”. IF¥es" to any of ines 4a-, Ist the persons and provi the applicable amounts for each iiem in Par i ac ‘Only section 01(¢)(2), 01(c)4), and 501(c)(29) organizations must complete lines 5-9. 5 For persons ksted m Form 990, Part Vi, Section A. line 18, did the organzaton pay or accrue ary compensation contingent on the revenues of 2 The organzaton? Any related organeston? "Yes" to ine 53 or 5b, desenbe m Part I 6 For persons listed in Form 990, Part VI, Secton A, ine 1a, did he organzation pay or accrue any compensation contingent on the net earnings of a The organzation? . Any related organzaton? \F¥es" to line 62 oF 6b, describe in Par Il 7 For persons listed in Form 990, Part VI, Section A, ine 1a, did the organization provide any non-inxed payments not described im lines 5 and 6? W"Yes," describe m Part I 8 Were any amounts reported in Form 990, Part Vl, paid or accrued pursuant to contract that was subject to the intial contract exception described in Regulations section 53 4958-4(a\3)? If "Yes" descrbe in Part 9 It "Yes" to line 8, did the organzation also follow the rebuttable presumption procedure described in Regulations secon 53 4958-6(c)? ee : oe . |e For Paperwork Reduction Act Notice, see the Insturbone fr Form 880. ‘Senegal J Form 90) 2036 Ties 702V 11/12/2015 4:20:26 BMV 14-7.6F PAGE 19 HEALTH REPUBLIC THSURANCE OF 45-3360081 ecto, Trustees, Kay Employees, and Highest Compensated Employees, Use Gipicale copes TSaSuona| space needed For each nda whose compenetion must be reoree Schedule repo comgensalen Wom the eenzaton on ow () ah Kom felted egonestons, desabea m he ‘natnesons, on row (Oe nal tat ay indies That ae not hsteg on Fath 990, Par ee Tem cos (Xf acd nea moat eh eal rset of Fem 0, Pa VN, Son Ae, aka con (0) (anit at eSIRA NT RTT ORME RIT rarenace | onmuaor | etenaawn |_pememmn, sony FONG fas] 100. Ta. 7 WILLIAW w. FRTEOMNN a 79, 5a Hae ° Pk a : z 7 exLTH ReFURLEC INGURANCS OF 45-s268081 ‘Supplemental Wormaton. Complete ths pat fo prow the sormalion explain, OF SGsarptone TeGured Tor Part, ines Ta, Tb, 8, 4a, 4b, 46, 6a, 6b, 68, 60,7, OB, wae PaR ‘Neo complete fs pa foray adStonl marmabon . SCHEDULEO Supplemental Information to Form 990 or 990-EZ ‘oua no 15480047 (Form 990 or 90-22) Complete to provide information for reeponses to specie questions on ccprnen nn tay orm 80 or 980-£2 or to provide ary additional information rarer ssearansasee Attach to Form $90 07 990.2, reser ave otteogeuiis —WERLTH REPUBLIC INSURANCE OF Tape Tanherson rebar NEW YORK, CORP. 45-3368051 FORM 990, PART V, LINE 13: THE ORGANIZATION INCORPORATED ON 10/13/2011, WAS GRANTED ITS LICENSE TO DO BUSINESS AS AN ARTICLE 43 INSURER IN THE STATE OF NEN YORK ON 7/22/2013. THE ORGANIZATION BEGAN ENROLLING CUSTOMERS ON 10/1/2013 FOR COVERAGE BEGINNING 3/1/2014. FORM 990, PART VI, SECTION A, LINE 4: IN 2014 THE PRE-OPERATIONAL BOARD WAS CHANGED 70 AN INTERIM BOARD AND FINALLY THE PROVISIONS SET FOR THE MEMBER-LED BOARD IN 2015. OUR THREE BOARD PHASES WERE CALLED FORMATION, INTERIM AND OPERATIONAL. FORM 990, PART VI, SECTION B, LINE 118: FORM 990 DRAFT IS REVIEWED BY THE CONTROLLER AND EF FINANCIAL OFFICER PRIOR 70 FILING WITH THE IRS. FORM 990 DRAFT IS DISTRIBUTED TO OFFICERS AND THE BOARD F INRNCE COMMITTEE FOR REVIEW. THE FINAL ORAFT IS PROVIDED 10 THE BOARD OF DIRECTORS PRIOR 70 FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C: PROSPECTIVE BOARD MEMBERS, NEW HIRE OFFICERS AND KEY EMPLOYEES MUST COMPLETE A CONFLICT OF INTEREST STATEMENT, SIGN AND FURNISH TO MANAGEMENT FOR REVIEW PRIOR TO APPOINTWENT/HIRE. ON AN ANNUAL BASIS THE CONFLICT OF INTEREST STATEMENT IS DISTRIBUTED 70 BOARD MEMBERS, NEW HIRE OFFICERS AND KEY EMPLOYEES AND THE SIGNED STATEMENTS SUBMITTED 70 THE ORGANIZATION. DIRECTORS AND OFFICERS SHALL KEEP THE BOARD OF DIRECTORS INFORMED OF For Privacy Act nd Paperwork Reduction Act Naice, 260 the Instuctons for Form 860 or 890.52 ‘Schedule © (Fam 690 or OED OTA) LI7BES 702V 11/12/2015 4:20:26 PMV 14-7.6F PAGE 22 Setecule 0 (For 9600 98062) 2018 Nevefiieopewston HEALTH REPUBLIC INSURANCE OF “Employer iseiicaton number NEWYORK, CORP. 45-3368051, CHANGES IN PERSONAL, BUSINESS OR ORGANIZATIONAL INTERESTS AND AFFILIATIONS THAT MAY GIVE RISE TO AN ACTUAL OR POTENTIAL CONFLICT OF INTEREST. FORM 990, PART VI, SECTION B, LINES 15A AND 158: ‘THE BOARD COMPENSATION COMMITTEE ANNUALLY REVIEWS THE FAIRNESS OF THE PRESIDENT/CEO'S COMPENSATION AND BENEFITS. IT UTILIZES DATA FROM COMPETENT SALARY SURVEYS OF EXECUTIVE COMPENSATION IN THE COMPARABLE HEALTH INSURANCE AND NOT-FOR-PROFIT INDUSTRIES. THE COMMITTEE HAS RECOMMENDED ADJUSTMENTS IN THE EXECUTIVE DIRECTOR'S COMPENSATION AND BENEFITS TO THE FULL BOARD FOR REVIEW AND APPROVAL. CONTEMPORANEOUS SUBSTANTIATION OF THE COMPENSATION DELIBERATION WAS MAINTAINED BY THE ORGANIZATION. THE COMMITTEE HAS ALSO REVIEWED THE RECOMMENDATIONS OF THE PRESIDENT/CEO REGARDING SALARY AND BENEFITS OF THE CFO AND OTHER KEY EMPLOYEES. FORM 990, PART VI, SECTION C, LINE 19: THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XI, LINE ‘TAE OTHER CHANGES IN NET ASSETS IS COMPRISED OF: SOLVENCY LOAN FROM CMS DISBURSED. +$122,491,214 CHANGE IN NON-ADMITTED ASSETS, PRINCIPALLY PREPAID EXPENSES AND SECURITY DEPOSIT.......$ (4,297,623) CORRECTION IN ERROR. . +8 (15,216) = ‘Schedule © (rom Seo or BHO ED aH "111 7eES 702V 11/12/2015 4:20:26 PM Vv 14-7.6F PAGE 23, ‘Sehedute 0 (Fem 990 1 9502) 2014 Pose 2 iNane oftreopevasten HEALTH REPOBLIC INSURANCE OF Epps eneon imbor NEW_YORK, CORP. 45-3368052 TOTAL. . 7 ppoopooncana $118,138, 475 FORM 990, PART XIZ, LINE 1: THE STATUTORY BASIS FINANCIAL STATEMENTS HAVE BEEN PREPARED IN CONFORMITY WITH THE ACCOUNTING PRACTICES PRESCRIBED OR PERMITTED BY THE NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES ("NYSDFS") mace 990, PART VII- COMPENSATION OF THE FIVE HIGHEST PAID IND. CONTRACTORS NAME_AND_ ADDRESS DESCRIPTION OF SERVICES COMPENSATION CONSENTIAHEALTH, LLC consuLTING 2,011,870. 12100 SINGLETREE LANE, SUITE 123 EDEN PRAIRIE, MN 55344 OPTIMITY ADVISORS, LLC consuurrNe 1,685,091 774483 350 EAST DEVON AVENUE ITASCA, IL 60143 ROPES 6 GRAY, LLP LEGAL 1,192,392. PO BOX 414265, BOSTON, MA 02242 CONVERGEDIRECT, LLC ADVERTISING 593,018. 100 SOUTH BEDFORD ROAD, SUITE 320 MOUNT KISCO, NY 10549 GLOBAL STRATEGY GROUP, LLC ConsuLTING 355,245. 895 BROADWAY, STH FLOOR NEW YORK, NY 10003 5 ‘Seheaule 0 (For 090 or OEE) IENA .i7eBs 702v 11/12/2015 0:26 PMV 14-7.6F PAGE 24 STATE OF NEW YORK DEPARTMENT OF STATE Ihereby certify that the annexed copy has been compared with the original document in the custody of the Secretary of State and that the same is a true copy of said original. WITNESS my hand and official seal of the Department of State, at the City of Albany, on October 14, 2014. ata ii Anthony Giardina Executive Deputy Secretary of State Rev. 06/13 oSc 45 (%1010000 (Ge Drawdown CERTIFICATE OF AMENDMENT OF THE CERTIFICATE OF INCORPORATION oF FREELANCERS HEALTH SERVICE CORPORATION ‘Under Section 803 of the Not-for-Profit Corporation Law eis hereby certified that: FIRST: The name of the corporation is Freelancers Health Service Corporation. SECOND: The certificate of incorporation of the corporation was filed by the Department of State on October 13, 2011. ‘THIRD: The corporation was formed under the Not-for-Profit Corporation Law. FOURTH: The corporetion is 2 corporation es defined in subparagraph (6X5) of Section 102 of the Not-for-Profit Corporation Law. FIFTH: The amendments of the cxtificate of incorporation of the corporation affected by this certificate of amendment are to change the name of the corporation and to change the post office address to which the Secretary of State shall msil a copy of any process against the corporation, SUXTH: To accomplish the foregoing amendments, Article FIRST of the certificate of incorporation of the corporation, relating to the corporate name, and Article SEVENTH of the certificate of incorporation of the corporetion, relating to the post office address to which the Secretary of State shell mail e copy of any process against the corporation, are hereby amended to read as follows: FIRST: The name of the not-for-profit corporation is Health Republic Insurance of New York, Corp. (the “Corporation”). SEVENTH: The Secretary of State of the State of New York (the “Sceretary”) is designated as the agent of the Corporation upon whom process against the Corporation may be served. The post office address within the State of New York to which ‘the Seoretary shall mail a copy of any provess against the Corporation served upon him is: entas.6 141010000086 ‘fo Corporation Service Company, 80 State Street, Albany, NY 12207-2543. SEVENTH: The foregoing amendments of the certificate of incorporation of the corporation were authorized at e meeting at which a quorum of the members entitled to vote ‘theceon was prescat, by at least a majority vote as provided in paragraph (c) of Section 613 of the ‘Not-for-Profit Corporation Law of the members of the corporation entitled to vote on the said ‘amendments ofthe certificate of incorporation. EIGHT: The Secretary is designated as the agent of the corporation upon whom process against the corporation may be served. The post office adéress within the State of New ‘York to which the Secretary shall mail a copy of any process against the corporation served upon ‘him is: eo Corporation Service Conapany, 80 State Steet, Albany, NY 12207-2543. [Remainder of page intentionally left blank} sans. 6 Signed on October F, 2014 cenieasss We a Sta ‘Name: Barbera Davis, ‘Title: Chair of the Board of Directors 1&t010000 CERTIFICATE OF AMENDMENT OF THE CERTIFICATE OF INCORPORATION or FREELANCERS HEALTH SERVICE CORPORATION. ee Ce STATE OF NEW YORK DEPARTMENT OF STATE FLED OCT 10 2014 Filed by: Ropes & Gray LLP ws. 1211 Avenue of the Americas New York, NY 10036 ® i Cust Raf HH 330703 Re 9855 HY OF Loo Hy OS Uy (et anne. | W.. ¥. 8. DEPARTMENT OF STATE DIVISION OF CORPORATIONS AND STATE RECORDS ENTITY NAME: HEALTH REPUBLIC INSURANCE OF NEW YORK, CORP. DOCUMENT TYP! PILED: ALBANY, NY 12231-0001 FILING RECEIPT AMENDMENT (DOMESTIC NFP) COUNTY: NEWY PROCESS NAME. 10/10/2014 DURATION: *###s##+ CASH#:141010000089 FILM #:141010000086 FILER: ROPES & GRAY LLP 1211 AVENUE OF THE AMERICAS NEW YORK, NY 10036 ADDRESS FOR PROCESS: C/O CORPORATION SERVICE COMPANY 80 STATE STREET ALBANY, NY 12207-2543 REGISTERED AGENT SERVICE COMPANY: CORPORATION SERVICE COMPANY - 45 SERVICE CODE: 45 FEES PAYMENTS 65.00 FILING 30.00 CASH TAK, 0.00 CHECK 0.00 CERT 0:00 CHARGE. 0.00 COPIES 10.00 DRAWDOWN 65.00 HANDLING 25.00 OPAL 0.00 REFUND 0.00 330703KXK DOS-1025 (04/2007)