2017-03-23T10:24:18-05:00 2016-06-30 061298465 SM ESPOSITO & CO PC 3013 DIXWELL AVENUE HAMDEN CT 06518 990 2015-07-01 060850110 TRI-STATE JOINT FUND TRI- 2038763120 25 RESEARCH DRIVE MILFORD CT 06460 JOHN CAPOBIANCO UNION CO-CHAIRMAN 2038763103 2017-03-23 1 DANA HARVEY CPA P01452206 2033877771 2017-03-22 2015 2021-01-29 14:40:06Z JOHN CAPOBIANCO 25 RESEARCH DRIVE MILFORD CT 06460 95605806 0 X N/A X 1968 CT SELF-INSURED HEALTH BENEFIT PLAN 26 26 14 0 0 0 0 0 84966326 92345312 1468638 303644 3268 1557 86438232 92650513 0 0 83123216 89170972 1249138 1244898 0 0 0 1738657 1840829 86111011 92256699 327221 393814 17711543 18432144 4687809 5264577 13023734 13167567 PROVIDE SELF-INSURED HEALTH AND WELFARE BENEFITS TO MEMBERS COVERED UNDER COLLECTIVE BARGAINING AGREEMENTS NEGOTIATED BY TEAMSTER LOCALS. 0 0 THE FUND OPERATES UNDER A TRUST AGREEMENT FOR THE PURPOSEOF MAKING BENEFIT PAYMENTS TO MEMBERS OF THE TRI-STATETEAMSTERS HEALTH SERVICES & INSURANCE PLAN, THESE BENEFITS COVER HOSPITAL,SURGICAL, PRESCRIPTION DRUG, HOME HEALTH CARE AND DEATH BENEFITS FOR 11,280 MEMBERS PLUS THEIR DEPENDENTS. 0 0 0 0 0 0 0 0 0 1 0 0 1 1 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 20 0 14 1 0 0 0 0 0 0 X 26 26 0 0 0 0 0 0 0 1 1 0 0 1 0 1 1 0 1 0 X SHARON AGNELLO 2038763120 25 RESEARCH DRIVE MILFORD CT 06460 DENNIS MCGUIRE EMPLOYER CO-CHAIRMAN & TRU 4.00 2.00 X 0 0 0 DANIEL FLANAGAN UNION TRUSTEE 1.00 4.00 X 0 0 0 THOMAS BAYUSIK UNION TRUSTEE 1.00 4.00 X 0 0 0 TIMOTHY CASEY EMPLOYER TRUSTEE 1.00 2.00 X 0 0 0 ANTHONY CAPPELLA EMPLOYER TRUSTEE 1.00 2.00 X 0 0 0 FOREST HARVEY EMPLOYER TRUSTEE 1.00 2.00 X 0 0 0 ED ROONEY UNION TRUSTEE 1.00 4.00 X 0 0 0 ROBERT FLYNN UNION TRUSTEE 1.00 4.00 X 0 0 0 FRANK ROSSI UNION TRUSTEE 1.00 4.00 X 0 0 0 VICTOR SANTIAGO UNION TRUSTEE 1.00 4.00 X 0 0 0 ROBERT SULLIVAN JR EMPLOYER TRUSTEE 1.00 2.00 X 0 0 0 LAWRENCE KEEFE EMPLOYER TRUSTEE 1.00 2.00 X 0 0 0 THOMAS SCHLINK UNION TRUSTEE 1.00 4.00 X 0 0 0 BEVAN SWEET UNION TRUSTEE 1.00 4.00 X 0 0 0 NICHOLAS REUT EMPLOYER TRUSTEE 1.00 2.00 X 0 0 0 JOHN HENDEL EMPLOYER TRUSTEE 1.00 2.00 X 0 0 0 JOHN LUPACCHINO UNION TRUSTEE 1.00 4.00 X 0 0 0 PEDRO DEPARA UNION TRUSTEE 1.00 4.00 X 0 0 0 CRAIG TIMPSON EMPLOYER TRUSTEE 1.00 2.00 X 0 0 0 DONALD SHUBERT EMPLOYER TRUSTEE 1.00 2.00 X 0 0 0 JOHN CAPOBIANCO UNION CO-CHARIMAN & TRUSTE 4.00 4.00 X 0 0 0 MICHAEL RINALDI UNION TRUSTEE 1.00 4.00 X 0 0 0 HELGA SCHMIDT EMPLOYER TRUSTEE 1.00 2.00 X 0 0 0 PAUL AYOUB EMPLOYER TRUSTEE 1.00 2.00 X 0 0 0 CHRISTOPHER ROOS UNION TRUSTEE 1.00 4.00 X 0 0 0 GLENN BARKSDALE UNION TRUSTEE 1.00 4.00 X 0 0 0 PAUL NOVAK EMPLOYER TRUSTEE 1.00 2.00 X 0 0 0 JAMES STACK EMPLOYER TRUSTEE 1.00 2.00 X 0 0 0 SHARON AGNELLO EXECUTIVE DIRECTOR 40.00 X 111165 0 41000 PATRICIA SANDILLO (FORMER) EXECUTIVE DIRECTO 10.00 X 57200 0 0 168365 0 41000 1 1 1 0 ROBERT M CHEVERIE & ASSOC 333 EAST RIVER DRIVE EAST HARTFORD CT 06108 LEGAL 362597 THE SEGAL COMPANY CHURCH STREET STATION P O BOX 4059 NEW YORK NY 102614059 ACTUARIAL 274365 SM ESPOSITO & COMPANY PC 3013 DIXWELL AVE HAMDEN CT 06763 ACCOUNTING/AUDITING 193640 EMDEONABF 3183 RIDER TRAIL SOUTH EARTH CITY MO 63045 PRINTING/MAILING 128486 SOFTWARE SYSTEM SOLUTIONS 212 NEW LONDON TPKE GLASTONBURY CT 06033 SOFTWARE CONSULTING 111966 5 CONTRIBUTIONS - HEALTH FUNDS 900099 92343662 92343662 RENTAL INCOME -AFFILIATE 900099 1650 1650 92345312 201842 201842 3057095 2946908 8385 110187 -8385 101802 -8385 110187 MISC REFUNDS 900099 1557 1557 1557 92650513 92338484 0 312029 89170972 661016 280224 245357 58301 404597 193640 57853 337190 240355 191913 133030 25563 45724 36079 36934 OUTSIDE SERVICES 128486 MEDICAL EQUIPMENT 9465 92256699 71475 60702 5857725 5353362 86120 84251 4871134 4425506 392096 445628 9657444 10011505 1646683 2476696 17711543 18432144 1029105 986452 3658704 4278125 4687809 5264577 X 0 0 0 0 13023734 13167567 13023734 13167567 17711543 18432144 393814 -249981 0 X X 0 1 X 1 0 152788 152788 3726127 3468969 257158 23081 23081 0 969138 933456 35682 445628 INTEREST RECEIVABLE 10891 MISCELLANEOUS RECEIVABLE 2367650 HEALTH BENEFIT RECONCILIATION 98155 2476696 DUE TO ANTHEM 2851181 DUE TO AFFILIATES 1415844 CLAIMS INCURRED BUT NOT RECEIVED 11100 4278125 X 92408918 -249981 1 -249980 92658898 -8385 -8385 92650513 92293086 2 2 92293084 -36385 -36385 92256699 PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE THE PLAN TO EVALUATE TAX POSITIONS TAKEN AND TO RECOGNIZE A TAX LIABILITY FOR ANY UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS. THE PLAN IS SUBJECT TO ROUTINE AUDITS BY TAX AUTHORITIES; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THE PLAN FILES ITS FORM 990 IN THE U.S. FEDERAL JURISDICTION. THE PLAN BELIEVES THAT THE INCOME TAX RETURNS FOR YEARS ENDED JUNE 30, 2012 AND PRIOR ARE CLOSED YEARS AND THEREFORE, ARE NOT SUBJECT TO THE AUDIT PROCESS. PART XI, LINE 2D - OTHER ADJUSTMENTS: ROUNDING ADJUSTMENT 1. PART XI, LINE 4B - OTHER ADJUSTMENTS: LOSS ON DISPOSITION OF FIXED ASSETS -8,385. PART XII, LINE 2D - OTHER ADJUSTMENTS: ROUNDING ADJUSTMENT 2. PART XII, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN BENEFIT OBLIGATION -28,000. LOSS ON DISPOSITION OF FIXED ASSETS -8,385. X 0 0 0 SHARON AGNELLO EXECUTIVE DIRECTOR 111165 0 0 0 0 0 20500 0 20500 0 152165 0 0 0 PATRICIA SANDILLO (FORMER) EXECUTIVE DIRECTO 57200 0 0 0 0 0 0 0 0 0 57200 0 0 0 PART I, LINE 3 THE CO-CHAIRMEN REVIEW AND ADJUST THE COMPENSATION OF THE EXECUTIVE DIRECTOR ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION B, LINE 11 FORM 990 IS REVIEWED IN PERSON WITH THE CO-CHAIRMEN AND THE EXECUTIVE DIRECTOR PRIOR TO FILING OF THE RETURN. FORM 990, PART VI, SECTION B, LINE 15B THE CO-CHAIRMEN REVIEW AND ADJUST THE COMPENSATION OF THE EXECUTIVE DIRECTOR ON AN ANNUAL BASIS. FORM 990, PART VI, SECTION C, LINE 19 TRI-STATE JOINT FUND DOES NOT MAKE AVAILABLE TO THE GENERAL PUBLIC ANY OF ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY OR FINANCIAL STATEMENTS. FORM 990, PART X11, LINE 2C OVERSIGHT RESPONSIBILITY THERE HAS BEEN NO CHANGE IN THE OVERSIGHT RESPONSIBILITY. THE TRUSTEE'S ASSUME RESPONBILBILITY FOR THE AUDIT PROCESS INCLUDING SELECTION OF THE INDEPENDENT AUDITOR. IBT TEAMSTERS LOCAL 191 HEALTH SERVICE & INSURANCE PLAN 1139 FAIRFIELD AVENUE BRIDGEPORT CT 06605 060689974 AFFILIATED SELF INSURED HEALTH PLAN CT 501C-9 N/A 0 TEAMSTERS LOCAL 404 HEALTH SERVICE & INSURANCE PLAN 115 PROGRESS AVENUE SPRINGFIELD MA 01104 042174518 AFFILIATED SELF INSURED HEALTH PLAN MA 501C-9 N/A 0 TRANSPORTATION LOCAL 443 HEALTH SERVICE & INSURANCE PLAN 200 WALLACE STREET NEW HAVEN CT 06511 060690083 AFFILIATED SELF INSURED HEALTH PLAN CT 501C-9 N/A 0 GENERAL TEAMSTERS LOCAL 493 HEALTH SERVICE & INSURANCE PLAN 18 CRESENT STREET UNCASVILLE CT 06382 060689500 AFFILIATED SELF INSURED HEALTH PLAN CT 501C-9 N/A 0 TEAMSTERS LOCAL 559 HEALTH SERVICE & INSURANCE PLAN 400 CHAPEL ROAD UNIT 2-B SOUTH WINDSOR CT 06074 060683663 AFFILIATED SELF INSURED HEALTH PLAN CT 501C-9 N/A 0 TEAMSTERS LOCAL 677 HEALTH SERVICE & INSURANCE PLAN 1871 BALDWIN STREET WATERBURY CT 06706 060691862 AFFILIATED SELF INSURED HEALTH PLAN CT 501C-9 N/A 0 TEAMSTERS LOCAL 1035 HEALTH SERVICE & INSURANCE PLAN 400 CHAPEL ROAD UNIT 2-A SOUTH WINDSOR CT 06074 060997832 AFFILIATED SELF INSURED HEALTH PLAN CT 501C-9 N/A 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 IBT TEAMSTERS LOCAL 191 HEALTH SERVICE & INSURANCE PLAN L 665000 TEAMSTERS LOCAL 404 HEALTH SERVICE & INSURANCE PLAN L 333760 TRANSPORTATION LOCAL 443 HEALTH SERVICE & INSURANCE PLAN L 462320 GENERAL TEAMSTERS LOCAL 493 HEALTH SERVICE & INSURANCE PLAN L 262040 TEAMSTERS LOCAL 559 HEALTH SERVICE & INSURANCE PLAN L 202360 TEAMSTERS LOCAL 677 HEALTH SERVICE & INSURANCE PLAN L 852920 TEAMSTERS LOCAL 1035 HEALTH SERVICE & INSURANCE PLAN L 271400