2018-03-05T17:57:05-06:00 2017-06-30 MILLER KAPLAN ARASE LLP 4123 LANKERSHIM BLVD NORTH HOLLYWOOD CA 916022828 990 2016-07-01 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 2018-03-05 true Jeffrey Goss P00349311 8187692010 204.1.171.253 95416620180645000002 2018-03-05 P F76BA963C288844E0E16B237C844EF342B7ECE99 8C6E67AC980B7473522F3092D30D7F22078FCE35 2016 2021-01-29 14:40:06Z Dan Clay 12205 SW TUALATIN RD STE 200 tualatin OR 97062 330196526 false X N/A X 1977 OR See Schedule O 10 10 0 0 0 0 0 146083995 154178153 779448 1710787 0 0 146863443 155888940 0 0 119413265 116927826 0 0 0 0 0 3267859 2828099 122681124 119755925 24182319 36133015 137220404 173724680 27469123 28034482 109751281 145690198 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 false 0 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 X CINDY THORNTON TRUSTEE 1.0 0.0 X 0 0 0 DAN CLAY TRUSTEE 1.0 0.0 X 0 0 0 JEFF ANDERSON TRUSTEE 1.0 0.0 X 0 0 0 kevin billman 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 LYNDA HART TRUSTEE 1.0 0.0 X 0 0 0 LISA dupell LOUCKS ALTERNATE TRUSTEE 1.0 0.0 X 0 0 0 sean hammond alternate trustee 1.0 0.0 X 0 0 0 JEFF CUELLAR ALTERNATE TRUSTEE 1.0 0.0 X 0 0 0 Katie Walter TRUSTEE 1.0 0.0 X 0 0 0 scott powers trustee 1.0 0.0 X 0 0 0 0 0 0 0 false false false ZENITH AMERICAN SOLUTIONS 12205 SW TUALATIN RD STE 200 TUALATIN OR 97062 CONTRACT ADMIN. 1589622 regence bluecross blueshield po box 1271 m/s ella PORTLAND OR 97027 ppo provider 4604748 ENVISION PHARMACEUTICAL SERVICES L 2181 E AURORA RD STE 201 TWINSBURG OH 44087 PHARMACY PROVIDER 537241 jthayer company 15802 Upper Boones Ferry Rd LAKE OSWEGO OR 97035 PRINTING & OFC SUPPL 162203 LOOMIS SAYLES CO LP ONE Financial Ctr BOSTON MA 02111 INVESTMENT MGR. 220064 5 0 EMPLOYER CONTRIBUTIONS 900099 143565523 143565523 EMPLOYEE CONTRIBUTIONS 900099 10612630 10612630 154178153 1680695 1680695 0 0 0 0 0 174337678 174307586 30092 30092 30092 0 0 0 0 0 0 0 0 0 0 155888940 154178153 1710787 0 0 0 116927826 0 0 0 0 0 0 1193220 83098 48659 0 0 253448 281115 0 417661 0 0 0 0 0 20421 0 0 0 72984 PCORI FEES 34781 TRANSITIONAL REINSURANCE FEES 422712 119755925 29306987 45994984 0 0 0 0 13605498 14966894 0 0 0 0 0 0 0 0 10836 78896 0 0 94297083 112683906 0 0 0 0 0 0 0 0 137220404 173724680 139142 207240 0 0 0 0 0 0 0 0 0 0 0 0 0 0 27329981 27827242 27469123 28034482 X 0 0 0 0 109751281 145690198 109751281 145690198 137220404 173724680 36133015 -194098 X false true X true 0 CLAIMS INCURRED BUT NOT REPORTED 8370000 ACCUMULATED ELIGIBILITY CREDITS 18185959 CLAIMS PAYABLE 1271283 27827242 X 155694842 -194098 -194098 155888940 155888940 119755925 119755925 119755925 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 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. 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 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.