2020-02-12T11:30:54-06:00 2019-04-30 320043599 LEGACY PROFESSIONALS LLP 4 WESTBROOK CORPORATE CTR 700 WESTCHESTER IL 60154 990 2018-05-01 846044454 ROCKY MOUNTAIN UFCW UNIONS & EMPLOYERS HEALTH BENEFIT FUND ROCK 3034301118 5511 W 56TH AVE NO 250 ARVADA CO 800022815 KEVIN SCHNEIDER TRUSTEE 3034301118 2020-02-12 1 BRUCE PAVLIK P00748405 3123680500 12.235.239.120 2020-02-12 11:30:51 CS P DBF743AF1216C3B70D6C9C598EE47CA4DBC4F1E6 013BD4BEA457AB31DE8385915B9401809CC4B7ED 2018 2020-04-17 16:48:07Z KEVIN SCHNEIDER 5511 W 56TH AVE NO 250 ARVADA CO 800022815 152126020 0 X N/A X 1965 CO PROVIDE HEALTH BENEFITS 8 4 0 0 0 0 0 0 122823204 117023707 325265 743196 62219 144283 123210688 117911186 0 0 111003225 113879571 0 0 0 0 0 8981929 9122975 119985154 123002546 3225534 -5091360 50511678 45762361 569429 800079 49942249 44962282 TO PROVIDE HEALTH BENEFITS TO THE ELIGIBLE PARTICIPANTS AND DEPENDENTS OF ROCKY MOUNTAIN UFCW & EMPLOYERS HEALTH BENEFIT PLAN. 0 0 TO PROVIDE HEALTH, LIFE, ACCIDENTAL DEATH AND DISMEMBERMENT, DENTAL, VISION, PRESCRIPTION AND TEMPORARY DISABILITY BENEFITS TO ELIGIBLE PARTICIPANTS AND THEIR DEPENDENTS. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 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 0 0 0 0 X 8 4 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X ZENITH AMERICAN SOLUTIONS 3034301118 5511 W 56TH AVE NO 250 ARVADA CO 80002 STEVE DICROCE TRUSTEE 1.00 X 0 0 0 BOB MCLAUCHLIN TRUSTEE 1.00 X 0 0 0 DANNY MA TRUSTEE 1.00 X 0 0 0 KIM CORDOVA TRUSTEE 1.00 45.00 X 0 192782 12090 KEVIN SCHNEIDER TRUSTEE 1.00 45.00 X 0 170654 10736 NATHANIEL BERNSTEIN TRUSTEE - PAST 1.00 45.00 X 0 163838 10736 LEROY WESTMORELAND TRUSTEE 1.00 X 0 0 0 MARTIN GARCIA TRUSTEE 1.00 45.00 X 0 153242 10677 DALE LEE - NEW TRUSTEE - NEW 1.00 45.00 X 0 163838 10736 0 844354 54975 0 0 1 0 ZENITH AMERICAN SOLUTIONS 5511 W 56TH AVE STE 250 ARVADA CO 80002 THIRD PARTY ADMINISTRATOR 2352045 SPENCER FANE LLP 1700 LINCOLN ST STE 2000 DENVER CO 80203 LEGAL SERVICES 169851 REINHART BOERNER VAN DEUREN SC 1000 N WATER ST STE 1700 MILWAUKEE WI 53202 LEGAL SERVICES 165539 LEGACY PROFESSIONALS LLP 4 WESTBROOK CORPORATE CTR STE 700 WESTCHESTER IL 60154 ACCOUNTING SERVICES 158053 THE SEGAL COMPANY INC 101 N WACKER DRIVE STE 500 CHICAGO IL 60606 CONSULTING SERVICES 117947 5 EMPLOYER CONTRIBUTIONS 900099 101395892 101395892 PARTICIPANT CONTRIBUTIONS 900099 11440504 11440504 PRESCRIPTION REBATES 900099 3960710 3960710 MEDICARE PT. D RETIREE DRUG SUBSI 900099 226601 226601 117023707 826347 826347 34131683 34214834 -83151 -83151 -83151 COMMISSION CREDITS 900099 128424 128424 MISCELLANEOUS INCOME 900099 15859 15859 144283 117911186 117023707 0 887479 113879571 2148064 483365 88840 21261 5934170 335438 23913 51319 FEES MANDATED BY ACA 36605 123002546 1967064 6601094 38742268 13944799 9751690 8724038 50656 49027 16443403 50511678 45762361 138499 385219 430930 414860 569429 800079 X 0 0 0 0 49942249 44962282 49942249 44962282 50511678 45762361 -5091360 111393 0 X X 0 1 X 1 0 0 X 108984547 111393 111393 108873154 21261 9016771 9038032 117911186 113268978 0 113268978 21261 9712307 9733568 123002546 PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE THE PLAN TO EVALUATE TAX POSITIONS TAKEN BY THE PLAN AND RECOGNIZE A TAX LIABILITY IF THE PLAN HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY TAX AUTHORITIES. THE PLAN IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. PART XI, LINE 4B - OTHER ADJUSTMENTS: RETIREE PLAN - EMPLOYER CONTRIBUTIONS 2,738,984. RETIREE PLAN - INVESTMENT INTEREST 64,894. RETIREE PLAN - RETIREE CONTRIBUTIONS 5,101,183. RETIREE PLAN - PRESCRIPTION REBATES 756,685. RETIREE PLAN - MEDICARE PT. D RETIREE DRUG SUBSIDIES 226,601. RETIREE PLAN - COMMISSION CREDITS 128,424. PART XII, LINE 4B - OTHER ADJUSTMENTS: RETIREE PLAN - MEDICAL BENEFITS 2,998,814. RETIREE PLAN - PRESCRIPTION BENEFITS 3,322,554. RETIREE PLAN - MEDICAL PREMIUMS 2,604,994. RETIREE PLAN - HMO PREMIUMS 276,164. RETIREE PLAN - PPO FEES & PROVIDER FEES 167,752. RETIREE PLAN - ADMINISTRATIVE EXPENSES 337,904. RETIREE PLAN - FEES MANDATED BY ACA 4,125. 0 0 0 KIM CORDOVA TRUSTEE 0 181682 0 0 0 11100 0 2184 0 9906 0 204872 0 0 KEVIN SCHNEIDER TRUSTEE 0 159554 0 0 0 11100 0 2184 0 8552 0 181390 0 0 NATHANIEL BERNSTEIN TRUSTEE - PAST 0 152738 0 0 0 11100 0 2184 0 8552 0 174574 0 0 MARTIN GARCIA TRUSTEE 0 153242 0 0 0 0 0 2125 0 8552 0 163919 0 0 DALE LEE - NEW TRUSTEE - NEW 0 152738 0 0 0 11100 0 2184 0 8552 0 174574 0 0 FORM 990, PART VI, SECTION A, LINE 3 THE BOARD OF TRUSTEES HAS DELEGATED THE RECORD KEEPING AND DAY TO DAY ADMINISTRATION OF THE PLAN TO ZENITH AMERICAN SOLUTIONS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PROVIDED TO THE ENTIRE BOARD OF TRUSTEES AND PLAN ADMINISTRATOR PRIOR TO FILING. AFTER THE BOARDS' REVIEW, THE FORM IS APPROVED AND FILED. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF TRUSTEES IS REQUIRED TO DISCLOSE ANY NONADHERENCE TO THE ADOPTED POLICY. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST AT THE PLAN OFFICE. ROCKY MTN UFCW UNIONS AND EMPRS RETAIL AND MEAT PENSION PLAN 5511 W 56TH AVE SUITE 250 ARVADA CO 80002 846045986 PROVIDE PENSION BENEFITS TO ELIGIBLE PARTICIPANTS AND BENEFICIARIES CO 401(A) N/A 0 UNITED FOOD AND COMMERICAL WORKERS INTERNATIONAL UNION 7R LOCAL CONTRIBUTING EMPLOYER 0 ALBERTSONS SAFEWAY CONTRIBUTING EMPLOYER 0 ALMAGNO FREELANCE CONTRIBUTING EMPLOYER 0 DARLING INTERNATIONAL CONTRIBUTING EMPLOYER 0 DEBONAIRE HAIR CONTRIBUTING EMPLOYER 0 DENVER PROCESSING (KS - MEAT PLANT) CONTRIBUTING EMPLOYER 0 KING SOOPERSCITY MARKETSMITH FOODS CONTRIBUTING EMPLOYER 0 THE PERFECT TOUCH CONTRIBUTING EMPLOYER 0 ZENITH AMERICAN SOLUTIONS CONTRIBUTING EMPLOYER 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ROCKY MOUNTAIN UFCW UNIONS & EMPLOYERS RETAIL AND MEAT PENSION PLAN S 3921605 COST