2017-05-02T11:24:25-05:00 2016-11-30 320043599 LEGACY PROFESSIONALS LLP 311 S WACKER DRIVE STE 4000 CHICAGO IL 60606 990 2015-12-01 351065816 UNITED FOOD & COMM WORKERS CALUMET REGION INSURANCE FUND UNIT 8473847000 9801 WEST HIGGINS ROAD NO 500 ROSEMONT IL 60018 ROBERT NIKSA FUND ADMINISTRATOR 8473847000 2017-05-02 1 BRUCE A PAVLIK P00748405 3123680500 2015 2021-01-29 14:40:06Z ROBERT NIKSA 9801 WEST HIGGINS ROAD NO 500 ROSEMONT IL 60018 10661468 0 X N/A X 1960 IL PROVIDE HEALTH BENEFITS 4 4 0 0 0 0 0 0 7959555 8006516 121627 144069 810 17654 8081992 8168239 0 0 9422683 8874278 0 0 0 0 0 567483 522483 9990166 9396761 -1908174 -1228522 7782021 6601662 64187 40556 7717834 6561106 PROVIDE HEALTH BENEFITS 0 0 TO PROVIDE HEALTH AND WELFARE, DEATH, AND LOSS OF TIME BENEFITS TO ELIGIBLE PARTICIPANTS AND/OR 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 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 48 0 1 0 0 0 0 0 0 0 0 0 X 4 4 0 1 0 0 0 0 0 1 0 0 0 1 1 0 0 1 0 0 0 0 X ROBERT NIKSA 8479397220 9801 WEST HIGGINS ROAD ROSEMONT IL 60018 X STEVEN POWELL TRUSTEE 3.00 X 0 0 0 SAMUEL VAN TIL TRUSTEE 3.00 X 0 0 0 LISA CATANZARO TRUSTEE 3.00 X 0 0 0 JEFFREY STRACK TRUSTEE 3.00 X 0 0 0 HARRY GROW TRUSTEE - ALTERNATE 3.00 X 0 0 0 DEREK KINNEY TRUSTEE - ALTERNATE 3.00 X 0 0 0 0 0 0 0 0 0 0 BLUE CROSS BLUE SHIELD 300 EAST RANDOLPH ST CHICAGO IL 60601 PPO PROVIDER 466991 1 EMPLOYER CONTRIBUTIONS 900099 7870993 7870993 STOP LOSS REFUNDS 900099 106072 106072 PARTICIPANT CONTRIBUTIONS 900099 29451 29451 8006516 176736 176736 2460562 2493229 -32667 -32667 -32667 MISCELLANEOUS 900099 17654 17654 17654 8168239 8006516 0 161723 8874278 319215 6669 30292 40670 90453 12223 1112 12477 WEB CLAIMS SERVICE FEE 5553 FEES MANDATED BY ACA 3819 9396761 114628 54934 613585 74310 93098 88871 5326 6041 6919009 6349247 36375 28259 7782021 6601662 38437 40556 25750 0 64187 40556 X 0 0 0 0 7717834 6561106 7717834 6561106 7782021 6601662 -1228522 71794 0 X 0 1 X 1 0 0 X 8199363 71794 71794 8127569 40670 40670 8168239 9356091 0 9356091 40670 40670 9396761 PART X, LINE 2: THE PLAN FILES FORM 990, RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX AND FORM 5500, ANNUAL RETURN/REPORT OF EMPLOYEE BENEFIT PLAN. THE PLAN'S RETURNS ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE UNTIL THE APPLICABLE STATUTE OF LIMITATION EXPIRES. FORM 990, PART VI, SECTION A, LINE 3 THE PLAN IS ADMINISTERED AND MANAGED BY THE UNITED FOOD AND COMMERCIAL WORKERS UNION AND EMPLOYERS (UFCW) MIDWEST HEALTH BENEFITS FUND. THE PLAN REIMBURSES THE UFCW MIDWEST HEALTH BENEFITS FUND FOR CERTAIN COMMON ADMINISTRATIVE EXPENSES BASED ON A PER MEMBER FEE AGREEMENT. FORM 990, PART VI, SECTION A, LINE 8B THE PLAN HAS NO COMMITTEES WITH THE AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY (TRUSTEES). FORM 990, PART VI, SECTION B, LINE 11 THE COMPLETED FORM 990 IS PROVIDED TO THE ENTIRE BOARD OF TRUSTEES. ONCE THE FORM IS REVIEWED AND APPROVED, IT IS SIGNED AND FILED. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS,CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST AT THE FUND OFFICE. STRACK-ULTRA LLC CONTRIBUTING EMPLOYER 0 LAKE COUNTY NURSING INC CONTRIBUTING EMPLOYER 0 HAPPY FOODS INC CONTRIBUTING EMPLOYER 0 CENTRAL MARKET CONTRIBUTING EMPLOYER 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1