2022-05-13T18:26:44-05:00 2021-06-30 MILLER KAPLAN ARASE LLP 600 STEWART ST STE 618 SEATTLE WA 981011261 990 2020-07-01 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 2022-05-12 true PATI PIRO-BOSLEY 999009999 Catalina Kirby P02018896 2065963930 3 2020 2022-09-23 18:48:47Z Dan Clay 12205 SW TUALATIN RD STE 200 tualatin OR 97062 249461019 false X N/A X 1977 OR See Schedule O 10 10 0 0 0 0 0 0 48680019 124624469 4345996 8493290 0 0 53026015 133117759 0 0 130875498 137824449 0 0 0 0 0 2547905 2868001 133423403 140692450 -80397388 -7574691 160650818 151793952 31480456 33883235 129170362 117910717 X SEE SCHEDULE O false false see schedule o false false false false false false false false false false 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 TERESA POLLOCK TRUSTEE 1.0 0.0 X 0 0 0 SANDY HUMPHREY 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 JIM SINCLAIR Trustee 1.0 0.0 X 0 0 0 KYLE BRITTINGHAM TRUSTEE 1.0 0.0 X 0 0 0 scott powers trustee 1.0 0.0 X 0 0 0 ESAI ALDAY Alternate Trustee 1.0 0.0 X 0 0 0 RAGINI GUPTA Alternate Trustee 1.0 0.0 X 0 0 0 SHARON CARROLL 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 2148073 Zenith American Solutions 12205 SW Tualatin Rd Ste 200 TUALATIN OR 97062 Contract Admin. 3393342 Innovative Care Management Inc PO BOX 22386 PORTLAND OR 97269 Claims Management 924448 THE SEGAL COMPANY 180 HOWARD ST STE 110 SAN FRANCISCO CA 94105 CONSULTANT 284975 ACTIVERADAR SW HOLDINGS INC 11344 COLOMA RD STE 680 GOLD RIVER CA 95670 CLAIMS ADMINISTRATOR 171289 5 0 EMPLOYER CONTRIBUTIONS 900099 116451633 116451633 0 0 EMPLOYEE CONTRIBUTIONS 900099 8172836 8172836 0 0 124624469 723696 0 0 723696 0 0 0 0 0 124112854 116343260 7769594 7769594 0 0 7769594 0 0 0 0 0 0 0 0 0 0 133117759 124624469 0 8493290 0 0 0 137824449 0 0 0 0 0 0 1243514 45600 36185 0 0 310781 439814 0 685822 0 0 0 0 0 0 0 0 0 68833 PCORI FEES 37452 140692450 12176587 35729921 0 0 0 0 2127994 14831609 0 0 0 0 0 0 0 0 0 0 0 0 146346237 25746749 0 75485673 0 0 0 0 0 0 160650818 151793952 115655 178386 0 0 0 0 0 0 0 0 0 0 0 0 0 0 31364801 33704849 31480456 33883235 X 0 0 0 0 129170362 117910717 129170362 117910717 160650818 151793952 -7574691 -3684954 X false true X true 0 CLAIMS INCURRED BUT NOT REPORT 9748111 ACCUMULATED ELIGIBILITY CREDIT 21731849 CLAIMS PAYABLE 2224889 33704849 X 129432805 -3684954 -3684954 133117759 133117759 138352402 138352402 2340048 2340048 140692450 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: INCREASE 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 DISMEMBERSHIP 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. false false false false false false false false false false false false false false false false false false false SCHEDULE R - IDENTIFICATION OF RELATED-PARTY ORGANIZATIONS: THIS INFORMATION IS NOT MAINTAINED BY THE ADMINISTRATIVE OFFICE. IF SPECIFIC INFORMATION IS NEEDED, PLEASE CONTACT THE ADMINISTRATIVE OFFICE.