2023-05-15T11:23:49-05:00 2022-06-30 MILLER KAPLAN ARASE LLP 600 STEWART ST STE 618 SEATTLE WA 981011261 990 2021-07-01 237017278 UFCW LOCAL 555-EMPLOYERS HEALTH TRUST % PATI PIRO-BOSLEY UFCW 8667967623 12205 SW Tualatin Rd ste 200 TUALATIN OR 97062 PATI PIRO-BOSLEY Plan Administrator 8667967623 2023-05-11 true PATI PIRO-BOSLEY 999009999 Catalina Kirby P02018896 2065963930 2 2021 2023-04-26 12:10:37Z Dan Clay 12205 SW TUALATIN RD STE 200 tualatin OR 97062 146800545 false X N/A X 1977 OR See Schedule O 10 10 0 0 0 0 0 0 124624469 138692794 8493290 1238653 0 0 133117759 139931447 0 0 137824449 137134521 0 0 0 0 0 2868001 2660920 140692450 139795441 -7574691 136006 151793952 148467269 33883235 36660329 117910717 111806940 X SEE SCHEDULE O false false see schedule o false false false false false false false false false true false false true true true false false false false false false false false false false false false false false false false false false false false false false false false true false false true 0 0 0 false false false false false false false false X 10 10 false true false false false false false true true false false true true true true true true false X PATI PIRO-BOSLEY 8667967623 12205 SW TUALATIN RD STE 200 TUALATIN OR 97062 X Sean Hammond TRUSTEE 1.0 0.0 X 0 0 0 DAN CLAY TRUSTEE 1.0 0.0 X 0 0 0 MIKE MARSHALL TRUSTEE 1.0 0.0 X 0 0 0 BRENT BOHN trustee 1.0 0.0 X 0 0 0 Frank Jorgensen trustee 1.0 0.0 X 0 0 0 SCOTT POWERS TRUSTEE 1.0 0.0 X 0 0 0 SHARON CARROLL ALTERNATE TRUSTEE 1.0 0.0 X 0 0 0 ESAI ALDAY ALTERNATE TRUSTEE 1.0 0.0 X 0 0 0 TERESA POLLOCK TRUSTEE 1.0 0.0 X 0 0 0 Sandy Humphrey TRUSTEE 1.0 0.0 X 0 0 0 Kyle Brittingham TRUSTEE 1.0 0.0 X 0 0 0 Ragini Gupta Alternate TRUSTEE 1.0 0.0 X 0 0 0 Jim Sinclair TRUSTEE 1.0 0.0 X 0 0 0 Brian Caufield Alternate Trustee 1.0 0.0 X 0 0 0 0 0 0 0 false false false Regence Bluecross Blueshield PO Box 1271 M/S Elia PORTLAND OR 97027 PPO Provider 2023738 Zenith American Solutions 12205 SW Tualatin Rd Ste 200 TUALATIN OR 97062 Contract Admin. 3451340 Innovative Care Management Inc PO BOX 22386 PORTLAND OR 97269 Claims Management 833891 MAGELLAN RX MANAGEMENT 4801 E WASHINGTON ST STE 100 PHOENIX AZ 85034 PHARMACY BEN. MGMT 260973 ACTIVERADAR 5700 STONERIDGE MALL RD STE 260 PLEASANTON CA 94588 CLAIMS ADMINISTRATOR 160781 5 0 EMPLOYER CONTRIBUTIONS 900099 131325179 131325179 0 0 EMPLOYEE CONTRIBUTIONS 900099 7367615 7367615 0 0 138692794 554350 0 0 554350 0 0 0 0 0 7553401 6869098 684303 684303 0 0 684303 0 0 0 0 0 0 0 0 0 0 139931447 138692794 0 1238653 0 0 0 137134521 0 0 0 0 0 0 1225691 45600 40390 0 0 286976 340900 0 608929 0 0 0 0 0 10904 0 0 0 62566 PCORI FEES 38964 139795441 X 35729921 36743744 0 0 0 0 14831609 15494057 0 0 0 0 0 0 0 0 0 0 0 0 25746749 23797745 75485673 72431723 0 0 0 0 0 0 151793952 148467269 178386 185185 0 0 0 0 0 0 0 0 0 0 0 0 0 0 33704849 36475144 33883235 36660329 X 0 0 0 0 117910717 111806940 117910717 111806940 151793952 148467269 136006 -6239783 X false true X true COMMON/COLLECTIVE TRUST 72431723 F 72431723 0 CLAIMS INCURRED BUT NOT REPORT 13899260 ACCUMULATED ELIGIBILITY CREDIT 21693144 CLAIMS PAYABLE 882740 36475144 X 133691664 -6239783 -6239783 139931447 139931447 137025146 137025146 2770295 2770295 139795441 PART X, LINE 2: Accounting principles generally accepted in the United States of America require management to evaluate tax positions taken by the Plan and recognize a tax liability if the Plan has taken a tax position that more likely than not would not be sustained upon examination by a tax authority. 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: CHANGE IN BENEFIT OBLIGATIONS. part i, line 1 and part iii, lines 1 and 4a: TO PROVIDE MEDICAL, VISION, DENTAL, PRESCRIPTION, SUPPLEMENTAL INCOME, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS TO PARTICIPANTS ON WHOSE BEHALF EMPLOYERS CONTRIBUTE TO THE PLAN IN ACCORDANCE WITH THEIR COLLECTIVE BARGAINING AGREEMENT. part vi, line 11b: FORM 990 WAS reviewed by THE PLAN ADMINISTRATOR PRIOR TO FILING; ANY UNUSUAL ITEMS OR ITEMS NEEDING TO BE ADDRESSED WILL BE BROUGHT TO THE TRUSTEES' ATTENTION. part vi, line 12c: TRUSTEES ARE REQUIRED TO NOTIFY THE PLAN OF ANY CHANGES IN THEIR INTERESTS THAT COULD GIVE RISE TO CONFLICTS. part vi, line 19: THE PLAN DOCUMENT, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MAINTAINED IN THE PLANS' OFFICE AND ARE AVAILABLE UPON REQUEST. part vii, section a: TRUSTEE COMPENSATION AND BENEFITS FROM RELATED TAX-EXEMPT ORGANIZATIONS IS PROPERLY REPORTED AND AVAILABLE ON THOSE ORGANIZATIONS' TAX FILINGS. see part vii see part vii see part vii false false false false false false false false false false false false false false false false false false false PARTS II, III AND IV: IDENTIFICATION OF RELATED TAX-EXEMPT ORGANIZATIONS TAXABLE AS A PARTNERSHIP, CORPORATION OR TRUST: THE ADMINISTRATIVE OFFICE DOES NOT MAINTAIN THIS INFORMATION FOR THE PLAN'S CONTRIBUTING EMPLOYERS. PLEASE CONTACT THE ADMINISTRATIVE OFFICE IF YOU HAVE ANY QUESTIONS.