2017-03-15T17:21:13-05:00 2016-06-30 522385296 LINDQUIST LLP 5000 EXECUTIVE PARKWAY SUITE 400 SAN RAMON CA 945834210 990 2015-07-01 942541328 SHEET METAL WORKERS LOCAL 104 HEALTH CARE PLAN SHEE 9252089999 2610 CROW CANYON ROAD NO 200 SAN RAMON CA 94583 RICK WERNER TRUSTEE 9252089999 2017-03-15 1 JESSICA R ROSTER P01317380 9252779100 2015 2021-01-29 14:40:06Z RICK WERNER 2610 CROW CANYON ROAD SUITE 200 SAN RAMON CA 94583 124808953 0 X N/A X 1979 CA TO PROVIDE HEALTH BENEFITS AND SUPPLEMENTAL UNEMPLOYMENT BENEFITS 16 0 1095 0 0 0 0 0 91868534 104058804 2719767 2917087 0 0 94588301 106975891 0 0 77810730 83320569 50823 59240 0 0 0 4621988 4790854 82483541 88170663 12104760 18805228 105885560 128954559 28576757 32195122 77308803 96759437 TO PROVIDE HEALTH BENEFITS AND SUPPLEMENTAL UNEMPLOYMENT BENEFITS. 0 0 PROVIDED HEALTH AND WELFARE BENEFITS AND SUPPLEMENTAL UNEMPLOYMENT BENEFITS TO PARTICIPANTS AND THEIR ELIGIBLE DEPENDENTS. 0 0 0 0 0 0 0 0 0 0 0 0 0 1 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 X 997 0 1 1095 1 0 0 0 0 0 0 X 16 0 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X BENESYS INC 9252089999 2610 CROW CANYON ROAD SUITE 200 SAN RAMON CA 94583 X PAUL STECKEL TRUSTEE 4.00 X 0 0 0 GARLAND SELF JR TRUSTEE 1.00 X 0 0 0 CHRIS ENFANTINO TRUSTEE 1.00 X 0 0 0 BOB BRAMLETT TRUSTEE 1.00 X 0 0 0 BEN RIVERA TRUSTEE 1.00 X 0 0 0 MITCHELL HOPPE TRUSTEE 1.00 X 0 0 0 BRIAN MASTERS TRUSTEE 1.00 X 0 0 0 JOSEPH A MARACCINI TRUSTEE 5.00 X 0 0 0 DOMINIC TORREANO TRUSTEE 1.00 X 0 0 0 RICHARD WERNER TRUSTEE 1.00 X 0 0 0 WILLIE SOLIS TRUSTEE 1.00 X 0 0 0 KEITH DIAS TRUSTEE 1.00 X 0 0 0 STEVE LOPEZ TRUSTEE 1.00 X 0 0 0 SEAN O'DONOGHUE TRUSTEE 1.00 X 0 0 0 RANDY ATTAWAY TRUSTEE 1.00 X 0 0 0 ANTHONY URBINA TRUSTEE 1.00 X 0 0 0 SEE SCHEDULE O FOR COMPENSATION PAID BY RELATED ORGANIZATION 0.00 X 0 1 0 0 1 0 0 0 0 0 BENESYS INC 2610 CROW CANYON ROAD SUITE 200 SAN RAMON CA 94583 ADMINISTRATION 2358560 BLUE SHIELD OF CALIFORNIA 50 BEALE STREET SAN FRANCISCO CA 941051808 CLAIMS PROCESSING 813802 DELTA DENTAL OF CALIFORNIA PO BOX 997330 SACRAMENTO CA 958997330 CLAIMS PROCESSING 383513 KAUFMAN & GOBLE 160 W SANTA CLARA STREET SUITE 15 SAN JOSE CA 95113 CONSULTING 152500 ENVISION PHARMACEUTICAL SERVICES 1100 INVESTMENT BOULEVARD ELDORADO HILLS CA 95762 ADMINISTRATION 131981 6 EMPLOYER CONTRIBUTIONS 900099 91188681 91188681 EMPLOYEE CONTRIBUTIONS 900099 11014649 11014649 STOP LOSS INCOME 900099 936052 936052 MEDICARE - D REBATES 900099 757673 757673 SETTLEMENT INCOME 900099 161749 161749 104058804 3472777 3472777 17277372 17833062 -555690 -555690 -555690 106975891 104058804 0 2917087 83320569 59240 2259254 29862 57149 134962 1900926 160387 8396 27105 TRANSITIONAL INSURANCE 212804 MISCELLANEOUS EXPENSES 9 88170663 -365858 -164892 10665105 9146384 15804537 18745906 50264 50968 79731512 101176193 105885560 128954559 724566 1108502 904191 867620 26948000 30219000 28576757 32195122 X 0 0 0 0 77308803 96759437 77308803 96759437 105885560 128954559 18805228 645406 0 X X 0 1 X 1 0 0 ACCUMULATED ELIGIBILTY CREDITS 22119000 CLAIMS PAYABLE & INCURRED BUT NOT REPORTED 8100000 30219000 X 107486335 645406 645406 106840929 134962 134962 106975891 84764701 0 84764701 134962 3271000 3405962 88170663 PART X, LINE 2: THE PLAN'S ADMINISTRATOR HAS ANALYZED THE TAX POSITIONS TAKEN BY THE PLAN AND HAS CONCLUDED THAT, AS OF JUNE 30, 2016, THERE ARE NO UNCERTAIN POSITIONS TAKEN, OR EXPECTED TO BE TAKEN, THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE PLAN IS SUBJECT TO ROUTINE AUDITS BY THE TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THE PLAN'S ADMINISTRATOR BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR THE FISCAL YEARS PRIOR TO 2013. PART XII, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN BENEFIT OBLIGATIONS FORM 990, PART V, LINE 2A: THE PLAN DOES NOT HAVE ANY EMPLOYEES; HOWEVER, CERTAIN PARTICIPANTS OF THE PLAN RECEIVED A FORM W-2 FOR TAXABLE DOMESTIC PARTNER BENEFITS AND/OR UNEMPLOYMENT BENEFITS PROVIDED UNDER THE PLAN. FORM 990, PART VI, SECTION A, LINE 3 THE PLAN HAS CONTRACTED WITH BENESYS, INC. TO PROVIDE ADMINISTRATIVE SERVICES FOR THE ORGANIZATION. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 WAS PROVIDED TO THE BOARD OF TRUSTEES FOR REVIEW BEFORE IT WAS FILED. FORM 990, PART VI, SECTION B, LINE 12C TRUSTEES ARE REQUIRED TO DISCLOSE IN WRITING ANY RELATIONSHIPS OR INTEREST THAT COULD GIVE RISE TO A CONFLICT. IF THERE IS A CONFLICT OF INTEREST, THE CONFLICTING INTEREST IS FULLY DISCLOSED AND DOCUMENTED IN WRITING; THE TRUSTEE OR FIDUCIARY WITH THE CONFLICT OF INTEREST IS EXCLUDED FROM THE DISCUSSION AND APPROVAL OF SUCH TRANSACTION. FORM 990, PART VI, SECTION C, LINE 19 UPON REQUEST, THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT-OF-INTEREST POLICY AND FINANCIAL INFORMATION AVAILABLE. FORM 990, PART VII, SECTION A, LINE 1A: TRUSTEES ARE NOT COMPENSATED BY THE TRUST. COMPENSATION PAID TO TRUSTEES EMPLOYED BY OTHER RELATED ORGANIZATIONS IS REPORTED ON THE FORM 990 FILED WITH THE INTERNAL REVENUE SERVICE BY THE RELATED TAX EXEMPT ORGANIZATION. IF YOU WOULD LIKE ADDITIONAL INFORMATION, PLEASE CONTACT THE THIRD-PARTY ADMINISTRATOR, BENESYS, INC. FORM 990, PART XII LINE 2C: THE ORGANIZATION HAS A BOARD OF TRUSTEES THAT ASSUMES RESPONSIBLITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED. LOCAL 104 SUPPLEMENTAL PENSION PLAN 2610 CROW CANYON ROAD SUITE 200 SAN RAMON CA 94583 946560138 THE PLAN PROVIDES SUPPLEMENTAL PENSION BENEFITS CA 501A N/A N/A 0 SHEET METAL WORKERS PENSION TRUST OF NORTHERN CALIFORNIA 2610 CROW CANYON ROAD SUITE 200 SAN RAMON CA 94583 516115939 THE PLAN PROVIDES PENSION BENEFITS TO RETIREES CA 501A N/A N/A 0 SHEET METAL WORKERS INTERNATIONAL ASSN LOCAL UNION NO 104 2610 CROW CANYON ROAD SUITE 300 SAN RAMON CA 94583 940859420 UNION CA 501C(5) N/A N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SCHEDULE R, IDENTIFICATIN OF RELATED ORGANIZATIONS: THE FILING ORGANIZATION IS A TAFT-HARTLEY MULTIEMPLOYER TRUST THAT PROVIDES HEALTH AND WELFARE BENEFITS TO ELIGIBLE EMPLOYEES AND THEIR DEPENDENTS. AS OF JUNE 30, 2016, THERE ARE APPROXIMATELY 232 EMPLOYERS THAT CONTRIBUTE TO THE TRUST. THE ADMINISTRATIVE OFFICE MAINTAINS A DATABASE OF THESE CONTRIBUTING EMPLOYERS, INCLUDING NAMES, ADDRESSES AND OTHER CONTACT INFORMATION. THE FEDERAL TAX CLASSIFICATION (DISREGARDED ENTITY, TAX-EXEMPT ORGANIZATION, PARTNERSHIP, TAXABLE CORPORATION OR TRUST) FOR EACH CONTRIBUTING EMPLOYER IS NOT ON FILE WITH THE ADMINISTRATIVE OFFICE AND IT COULD NOT BE REASONABLY OBTAINED. AS A RESULT, THE NAMES OF THE CONTRIBUTING EMPLOYERS ARE LISTED ON PART VII BELOW AND NOT ON PARTS II THROUGH IV BY FEDERAL TAX CLASSIFICATION. A G C, INC A I M SHEET METAL A QUALITY HEATING & AIR, INC. AAERO HEATING & S/M CO AAXON MECHANICAL INC. ABCO MECHANICAL CONTR ACCEL AIR SYSTEMS INC. ACCO ENGINEERED SYS ACI MECHANICAL INC. ADVANCED AIRE SYSTEMS ADVANCED SOLUTIONS,INC AIR CONDITIONING SYSTEM AIR EXCHANGE AIR SQUARED MECHANICAL AIR SYSTEMS ACQUISTION AIR SYSTEMS OF SACRAMENTO AIRCAL HTG. & S/M AIRCO MECHANICAL, INC. AIRE SHEET METAL AIRTEC SERVICE AKIMA, LLC ALES INSTALLATIONS ALL BAY MECHANICAL, INC. ALL TEMPERATURE SERVICE AIR ALLIED HTG & AIR COND ALPHA AIR BALANCING AG ALPINE MECH SERVICES AMERICAN METAL PROD ANDERSON ROWE & BUCKLEY ANNING JOHNSON APEX MECHANICAL, INC. APOLLO SHEET METAL INC. DBA ARENA & SONS ASCO SERVICE, INC. ASSOCIATED AIR BAL. & CERTIFIC AUTOMATED SOLUTIONS GROUP AXIS MECHANICAL BAY AREA BAL & CLEAN BAY CITY MECHANICAL BAY POINT CONTROL BAYSIDE HTG & A/C BEL AIR MECHANICAL BELL PRODUCTS BERLIN FOOD EQUIPMENT BEST CONTRACTING SERVICES BEUTLER CORPORATION BLOCKA CONSTR INC BOGNER SHEET METAL BOHN HEATING BONESO BROTHERS CONSTRUCT. INC BRADY AIR CONDITNG. BROADWAY MECH. CONTRACTORS BROADWAY S/M MFG INC BRUNS BELMONT CONSTRUCTION INC BUENA VISTA CONSTRUCTION BULLARD'S HEATING & AIR, INC. BURLINGAME HTG VENT CO C M F, INC. CAL-AIR/JOHNSON CONTROLS, INC. CALIFORNIA AIR INC CARMINE AIR CONDITIONING, INC. CARQUINEZ HEATING A/C & S/M CENTRAL COAST AIR INC. DBA CER MECHANICAL CORPORATION CHAMPION INDUSTRIAL CONTRACTOR CHUTE SYSTEMS CITY MECHANICAL, INC. CLINTON HTG & AIR COND COLD CRAFT COLTON HEATING COMFORT CONTROL COMFORT DYNAMICS INC. CONGI INC. DBA CARTER AIR CONTROL AIR NORTH INC CRANE HEATING & AIR COND. CRITCHFIELD MECHANICAL CROSS COUNTRY INSTALLATIONS & CROWN CORR, INC. CROWN SKYLIGHTS, INC. CULINARY STAINLESS FABRICATORS DDK MECHANICAL, INC. DEBELLA MECHANICAL,INC DEGREE HVAC, INC. DEHARO MECHANICAL INC. DELCON HEATING & A/C, INC. DELLA MORA HTG,S/M, & A/C, INC DEPENDABLE SHEET METAL DESERT MECHANICAL, INC. DOWDLE & SONS MECHANICAL, INC DOWNING HEATING & AIR COND. DYNAMIC MECHANICAL ENVIRONMENTAL SYSTEMS INC. ENVISE EXTREME AIR INC F S I F. W. SPENCER & SON, INC. FAIRVIEW HEATING & A/C FERTADO HEATING & AIR, INC. FOOTHILL AIR COND FRANK M BOOTH GAVILAN MECHANICAL, INC. GEORGE WILSON INC GLOBAL SPECIALTIES DIRECT, INC GOLDEN GATE S/M H-SQUARE MECHANICAL, INC. HARDIN & SONS, INC. HEATHORN & ASSOCIATES DBA HEATHORN MECH. SERVICES, INC. HVAC CAD SERVICE HVAC SERVICE HEATING & A/C INC I E S INDOO ENVIRO SVS ICOM MECHANICAL INDEPENDENT AIR BALANCE DBA INNOVATIVE MECH INC INSTALLSAREUS INTECH MECHANICAL CO., INC. IZMIRIAN ROOFING & S/M JAMES LONG CONSTRUCTION JAYCO MECHANICAL, INC. JEFFCO CUSTOM METALS, INC. JENSEN MECHANICAL, INC. JEROME & HORNER SHEET METAL JET MECHANICAL, INC. JMS MECHANICAL K & M INSTALLATION KAMRAN METAL WORKS, INC. KEL AIRE HTG KINETIC SYSTEMS, INC KINETICS MECHANICAL SVC KT MECHANICAL INC. L J KRUSE COMPANY LARGE'S METAL FAB LAWSON MECHANICAL LEED MECHANICAL LEFCO INC LETNER ROOFING LIMBACH COMPANY L.P LINCOLN AIR CON CORP LYLES MECHANICAL COMPANY, INC. M T B INCORPORATED M.E.S.A. 3, INC MARELICH MECHANICAL CO MARKEN MECHANICAL SERVICES MARTINEZ SHEET METAL MATRIX HEATING, INC. MAUCK SHEET METAL WORKS MECHANICAL TECHNOLOGIES CORP MELROSE METAL PRODUCTS MESA ENERGY SYSTEMS INC. METAL DESIGN & STRATEGY, INC. MG MCGRATH, INC. MICHAEL D BURNS COMPANY, INC. MILESTONE CONTRACTORS INC. DBA MINA METALS MONARCH MECHANICAL MONSTER MECHANICAL, INC. MONTEREY MECHANICAL CO NATIONAL AIR BALANCE NICHOLS PLUMBING & HEATING NORTH BAY COMMERCIAL SERVICES O C MCDONALD CO., INC. OMNI SHEET METAL, INC. ORSON MECHANICAL CO., INC. OTAVILLA MECHANICAL CONTR. PACIFIC COAST BALANCING PACIFIC COAST TRANE SVC PACIFIC TEST AND BALANCE, INC. PAN-PACIFIC MECHANICAL, LLC PARAGON MECHANICAL INC PATRIOT CONTRACTING, INC. PAUL WEST HTG. INC. PERFORMANCE AIR SERVICE, INC. PETERSON MECHANICAL, INC. PIONEER ROOFING ORGANIZATION POMI MECHANICAL INC. PRIME MECHANICAL SERVICE, INC. PRO TEMP MECHANICAL INC. PSF MECHANICAL, INC. QUALTECH MECHANICAL, INC. R H TINNEY R J MECHANICAL, INC RAY L HELLWIG MECH REACO HEATING & A/C REBARBER ENT.INC. RICH CORTEZ & SONS RMI MECHANICAL, INC. RODRIGUEZ SHEET METAL ROY MECHANICAL SERVICES, INC. RS ANALYSIS, INC. RYMAC, INC. S & H CONSTRUCTION, INC. S & L PAYTON, INC SAL J ACOSTA MFG CO INC SAN BENITO HEATING & S/M, INC. SANTA CLARA VLY CNTCRS SCHAFERS S/M & MFG CO SELCO HTG & A/C SERVICE MECHANICAL, INC. SERVICE METAL PROD INC SHEET METAL WORKERS SHEET METAL WRKS LU 104 SIERRA VALLEY HOME CORP. SILICON VALLEY MECHANICAL, INC SIMPSON SHEET METAL, INC. SMW 104 BAY AREA IND TRAIN FUN SOUTHLAND INDUSTRIES STALEY'S SHEET METAL STANDARD S/M & MARINE STATE OF CALIFORNIA STATE SHEET METAL WORKS STRUCTURAL & REFRIGERATION MEC SUPERIOR AIR HANDLING DBA SUPERIOR MECH. SERVICES, INC. T.A.B.C.O. INC TECTA AMERICA SACRAMENTO, INC. THE TIN MAN THERMA CORP. THERMAL MECHANICAL TRAYER ENGINEERING TULLEY MECHANICAL, INC. UNITED MECHANICAL, INC. VAL'S PLUMBING VALLEY SHEET METAL CO VAN MULDER SHEET METAL VENTEC VERDEGAAL HEATING INC WCASM INC, DBA WEST COAST ASM WEST COAST MECHANICAL WEST COAST TEST AND BALANCE WESTERN ALLIED MECHANICAL, INC WESTERN ENGINEERING SUPPLY CO YOUR WARM FRIEND,INC.