2024-10-15T16:36:28-05:00 2023-11-30 363168081 SIKICH LLC 17335 GOLF PARKWAY SUITE 500 BROOKFIELD WI 53045 990 2022-12-01 390979166 UNITED FOOD & COMMERCIAL WORKERS UNIONS & EMPLOYERS HEALTH PLAN UNIT 4144762523 5200 WEST LOOMIS ROAD GREENDALE WI 53129 JACOB BAILEY CHAIRMAN 4144762523 2024-10-15 1 1 BRIDGETTE MUGGE P00671418 2627549400 2024-10-08 2022 2024-10-15 13:58:12Z JACOB BAILEY 5200 WEST LOOMIS ROAD GREENDALE WI 53129 2879414 0 X N/A X 1960 WI HEALTH PLAN 6 3 0 3 0 0 0 0 2766595 2809708 56409 69623 0 83 2823004 2879414 0 0 2050005 2557033 0 0 0 0 0 449968 506047 2499973 3063080 323031 -183666 3611775 3600567 447666 612843 3164109 2987724 TO PROVIDE ELIGIBLE PARTICIPANTS ACCIDENT, HEALTH, VISION, DENTAL, PRESCRIPTION DRUG, LIFE INSURANCE, LOSS OF TIME, AND ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS. 0 0 ACCIDENT, HEALTH, LOSS-OF-TIME, DENTAL, LIFE, VISION CARE BENEFIT PAYMENTS TO PARTICIPANTS. PRESCRIPTION DRUG PROGRAM BENEFITS PAID ON BEHALF OF PARTICIPANTS. LIFE INSURANCE BENEFITS PAID ON BEHALF OF PARTICIPANTS. 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 X 6 3 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 X ZENITH AMERICAN SOLUTIONS 4144761220 5200 WEST LOOMIS ROAD GREENDALE WI 53129 JACOB BAILEY CHAIRMAN/UNION TRUSTEE 1.00 40.00 X X 0 159369 20665 CHAD WHITESIDE ALTERNATE UNION TRUSTEE 1.00 40.00 X 0 122275 20665 MELANIE BARTHOLF UNION TRUSTEE 1.00 40.00 X 0 145955 20665 DARREN HORNDASCH SECRETARY/EMPLOYER TRUSTEE 1.00 X X 0 0 0 TIMOTHY LAMERS EMPLOYER TRUSTEE 1.00 X 0 0 0 SHERRI BRYANT-SMITH EMPLOYER TRUSTEE 1.00 X 0 0 0 0 427599 61995 0 0 1 0 0 EMPLOYER CONTRIBUTIONS 525100 2801284 2801284 SELF PAY CONTRIBUTIONS 525100 8424 8424 2809708 69623 69623 CLASS ACTION LITIGATIO 525100 83 83 83 2879414 2809791 0 69623 2557033 90000 67069 90737 8693 7611 11391 STOP LOSS PREMIUMS 105132 ACCIDENT & HEALTH FEES 89794 BANK SERVICE FEES 19976 PROGRAM EXPENSE 14618 1026 3063080 1254976 1095326 2923 2923 278857 359469 14586 5513 2060433 2137336 3611775 3600567 139200 187862 175466 93981 133000 331000 447666 612843 X 0 0 0 0 3164109 2987724 3164109 2987724 3611775 3600567 -183666 7281 0 X 0 1 X 1 0 0 CLAIMS PAYABLE 331000 331000 X 2886695 7281 7281 2879414 0 2879414 2865080 0 2865080 198000 198000 3063080 PART X, LINE 2: THE TRUST ESTABLISHED UNDER THE PLAN TO HOLD THE PLAN'S ASSETS IS INTENDED TO QUALIFY PURSUANT TO SECTION 501(C)(9) OF THE INTERNAL REVENUE CODE (IRC) AND IS THEREFORE NOT SUBJECT TO TAX UNDER PRESENT INCOME TAX LAWS. THE TRUST HAS OBTAINED A FAVORABLE TAX EXEMPTION LETTER FROM THE INTERNAL REVENUE SERVICE (IRS), AND THE PLAN SPONSOR BELIEVES THAT THE TRUST AND THE PLAN, AS AMENDED, CONTINUE TO QUALIFY AND TO OPERATE IN ACCORDANCE WITH APPLICABLE PROVISIONS OF THE IRC. U.S. GAAP REQUIRE PLAN MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE PLAN AND RECOGNIZE A TAX LIABILITY (OR ASSET) IF THE PLAN HAS TAKEN AN UNCERTAIN TAX POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS. THE PLAN IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. PART XII, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN CURRENT YEAR CLAIMS PAYABLE 198,000. 0 0 0 JACOB BAILEY CHAIRMAN/UNION TRUSTEE 0 159369 0 0 0 0 0 4995 0 15670 0 180034 0 0 MELANIE BARTHOLF UNION TRUSTEE 0 145955 0 0 0 0 0 4995 0 15670 0 166620 0 0 FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PROVIDED TO THE FUND'S RECORDKEEPER. THEY REVIEW IT AND APPROVE IT, THEN PRESENT THE FORM 990 TO THE BOARD OF TRUSTEES FOR REVIEW AND FILING APPROVAL. FORM 990, PART VI, SECTION C, LINE 19 THEY ARE AVAILABLE UPON REQUEST. UNITED FOOD AND COMMERCIAL WORKERS LOCAL 1473 2001 NORTH MAYFAIR ROAD MILWAUKEE WI 53226 562585698 LABOR UNION WI 501(C)(5) N/A 0 BOARD OF TRUSTEES OF WI UFCW UNIONS AND EMPLOYERS HEALTH PLAN 2001 NORTH MAYFAIR ROAD MILWAUKEE WI 53226 390979166 PLAN SPONSOR AND PLAN ADMINISTRATOR WI 501(C)(9) N/A 0 UNION FIRST LASER TECHNOLOGIES INC PIGGLY WIGGLY MIDWEST SUPERIOR NATIONAL BANK & TRUST COMPANY WISCONSIN VISION FRED USINGER INC 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0