2024-05-15T13:26:14-05:00 2023-06-30 390859910 BAKER TILLY US LLP 2055 E WARNER RD STE 101 TEMPE AZ 85284 990 2022-07-01 208081486 NORTHWESTERN ARIZONA REGIONAL INSURANCE COMPANY NORT 6022222108 CO RPA 333 E OSBORN RD 300 PHOENIX AZ 85012 KRYSTAL BURGE PRESIDENT 6022222108 2024-05-14 1 KRYSTAL BURGE 999009999 0 COLETTE KAMPS CPA P00367616 4808394900 2024-05-14 3 AAL1 IAL1 2022 2023-04-26 12:10:37Z KRYSTAL BURGE 6074441 0 X N/A X 2006 AZ NORTHWESTERN ARIZONA REGIONAL INSURANCE COMPANY PROVIDES PROFESSIONAL LIABILITY, (CONT ON SCH O) GENERAL LIABILITY AND DIRECTORS AND OFFICERS' INSURANCE COVERAGE PURSUANT TO THE PROVISIONS OF ARIZONA REVISED STATUTES 20-1098. THE COMPANY CURRENTLY PROVIDES INSURANCE COVERAGE TO THE KINGMAN HOSPITAL, INC D/B/A KINGMAN REGIONAL MEDICAL CENTER. KINGMAN HOSPITAL, INC IS AN ARIZONA CORPORATION AND HAS BEEN RECOGNIZED AS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. 4 4 0 4 0 0 0 0 2019892 1966756 344370 380215 0 276434 2364262 2623405 3000000 1000000 0 0 0 0 0 0 0 334087 146249 3334087 1146249 -969825 1477156 16002570 16883134 6097127 5659405 9905443 11223729 X NORTHWESTERN ARIZONA REGIONAL INSURANCE COMPANY PROVIDES PROFESSIONAL LIABILITY, GENERAL LIABILITY, EMPLOYMENT PRACTICES LIABILITY AND DIRECTORS AND OFFICERS' INSURANCE TO ITS PARENT ORGANIZATION, THE KINGMAN HOSPITAL, INC. 0 0 1023300 1000000 2243190 NORTHWESTERN ARIZONA REGIONAL INSURANCE COMPANY PROVIDES PROFESSIONAL LIABILITY, GENERAL LIABILITY, EMPLOYMENT PRACTICES LIABILITY, AND DIRECTORS AND OFFICERS' INSURANCE COVERAGE PURSUANT TO THE PROVISIONS OF ARIZONA REVISED STATUTES 20-1098. THE COMPANY CURRENTLY PROVIDES INSURANCE COVERAGE TO THE KINGMAN HOSPITAL, INC D/B/A KINGMAN REGIONAL MEDICAL CENTER. KINGMAN HOSPITAL, INC IS AN ARIZONA CORPORATION AND HAS BEEN RECOGNIZED AS EXEMPT FROM INCOME TAXES UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE ORGANIZATION IS A WHOLLY-OWNED SUBSIDIARY OF THE KINGMAN HOSPITAL, INC. ITS ACTIVITIES WERE FUNDED THROUGH A CONTRIBUTION FROM KINGMAN HOSPITAL, INC. THE COMPANY IS LOCATED IN PHOENIX, AZ AND IS GOVERNED BY A BOARD OF DIRECTORS, WHILE DAILY OPERATIONS ARE CONDUCTED BY AN ADMINISTRATOR,(CONT. ON SCH O)ASHTON TIFFANY, LLC, IN EXCHANGE FOR AN ANNUAL FEE. SERVICES PROVIDED BY THE ADMINISTRATOR INCLUDE UNDERWRITING, POLICY ISSUANCE, ACCOUNTING, RECORD-KEEPING, REGULATORY LIAISON, AND NEW PROGRAM DEVELOPMENT. 1023300 1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 4 4 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 0 0 0 0 0 X RISK PROGRAM ADMINISTRATORS 6022222108 333 E OSBORN ROAD SUITE 300 PHOENIX AZ 85012 CORAL LLOYD SECRETARY 1.00 X X 0 0 0 JAMES BAKER VICE PRESIDENT 1.00 X X 0 0 0 KRYSTAL BURGE PRESIDENT 1.00 X X 0 0 0 CHRISTINA DIMAMBRO CFO, TRASURER 1.00 X X 0 0 0 0 0 0 0 0 0 0 0 PREMIUMS 524298 1966756 1966756 1966756 385352 385352 3445899 3451036 -5137 -5137 -5137 LOSS RECOVERIES 524298 276434 276434 276434 2623405 2243190 0 380215 1000000 1000000 51212 51212 565 565 18520 18520 52652 52652 17800 17800 DEPARTMENT OF INSURANCE 5500 5500 1146249 1023300 122949 0 407434 373500 1623170 1262290 332343 490324 13543618 14649945 96005 107075 16002570 16883134 16659 18833 332343 326883 5748125 5313689 6097127 5659405 X 650000 650000 0 0 9255443 10573729 9905443 11223729 16002570 16883134 1477156 -158870 0 X X 0 1 X 1 0 X X 1 KINGMAN HOSPITAL INC 942916102 3 1 1000000 0 1 1000000 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 PREFERRED STOCK 207853 F GOVERNMENT BONDS 658194 F CORPORATE BONDS 9646760 F ASSET-BACKED SECURITIES 4137138 F 14649945 RESERVE FOR OUTSTANDING LOSSES 140173 RESERVE FOR IBNR LOSSES 5173516 5313689 X 2411883 -158870 -158870 2570753 52652 52652 2623405 1093597 0 1093597 52652 52652 1146249 PART X, LINE 2: THE ORGANIZATION RECOGNIZES UNCERTAINTY IN INCOME TAXES IN THE FINANCIAL STATEMENTS WHEN IT IS MORE LIKELY-THAN-NOT THAT THE POSITIONS WILL NOT BE SUSTAINED UPON EXAMINATION BY THE TAX AUTHORITIES. AS OF JUNE 30, 2023, THE ORGANIZATION HAD NO UNCERTAIN TAX POSITIONS THAT QUALIFY FOR EITHER RECOGNITION OR DISCLOSURE IN THE FINANCIAL STATEMENTS. 1 KINGMAN HEALTHCARE INC 3269 STOCKTON HILL ROAD KINGMAN AZ 86409 942916102 501(C)(3) 1000000 0 GENERAL SUPPORT 1 0 PART I, LINE 2: DISTRIBUTIONS ARE ONLY MADE TO KINGMAN HOSPITAL, INC. WHICH IS A 501C3 ORGANIZATION. THE FILING ORGANIZATION IS A SUPPORTING ORGANIZATION TO KINGMAN HOSPITAL, INC. FORM 990, PART VI, SECTION A, LINE 2 OFFICERS HEATH EVANS AND TIMOTHY BLANCHARD HAVE A BUSINESS RELATIONSHIP THROUGH THEIR EMPLOYMENT AT THE ORGANIZATION'S PARENT ORGANIZATION, THE KINGMAN HOSPITAL, INC. MR. EVANS IS PRESIDENT AND CEO OF KINGMAN HOSPITAL AND MR. BLANCHARD IS THE CHIEF FINANCIAL OFFICER OF KINGMAN HOSPITAL. THE ONLY RELATIONSHIP THAT MR. EVANS AND MR. BLANCHARD HAVE WITH NORTHWESTERN ARIZONA REGIONAL INSURANCE COMPANY IS AS BOARD MEMBERS. FORM 990, PART VI, SECTION A, LINE 3 THE COMPANY'S DAILY OPERATIONS ARE CONDUCTED BY AN ADMINISTRATOR, ARTHUR J. GALLAGHER & CO., IN EXCHANGE FOR AN ANNUAL FEE. SERVICES PROVIDED BY THE ADMINISTRATOR INCLUDE UNDERWRITING, POLICY ISSUANCE, ACCOUNTING, RECORD-KEEPING, REGULATORY LIAISON AND NEW PROGRAM DEVELOPMENT. FORM 990, PART VI, SECTION A, LINE 6 THE COMPANY ALLOWS MEMBERS WHO ARE SELECTED NON-PROFIT HOSPITALS OPERATING WITHIN THE STATE OF ARIZONA. KINGMAN HOSPITAL, INC IS THE ONLY MEMBER OF THE COMPANY. FORM 990, PART VI, SECTION A, LINE 7A KINGMAN HOSPITAL, INC., THE COMPANY'S SOLE MEMBER, ELECTS ALL MEMBERS OF THE GOVERNING BODY. FORM 990, PART VI, SECTION A, LINE 7B DECISIONS BY THE GOVERNING BODY ARE SUBJECT TO APPROVAL BY KINGMAN HOSPITAL, INC., THE COMPANY'S SOLE MEMBER. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PROVIDED TO DIRECTOR TIMOTHY BLANCHARD FOR REVIEW AND APPROVAL. FORM 990, PART VI, SECTION B, LINE 12C ON AN ANNUAL BASIS, VOTING MEMBERS OF THE GOVERNING BODY ARE REQUESTED TO SIGN A CONFLICT OF INTEREST POLICY STATEMENT. FORM 990, PART VI, SECTION C, LINE 19 NORTHWESTERN ARIZONA REGIONAL INSURANCE COMPANY MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. 990, PAGE 12, PART XII, LINE 2C THE BOARD OF DIRECTORS REVIEWS AND APPROVES THE FINANCIAL STATEMENTS. KINGMAN HEALTHCARE INC 3269 STOCKTON HILL ROAD KINGMAN AZ 86401 942916102 HOSPITAL AZ 501(C)(3) LINE 3 N/A 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0