2016-04-07T10:30:32-05:00 2015-11-30 320043599 LEGACY PROFESSIONALS LLP 311 S WACKER DRIVE STE 4000 CHICAGO IL 60606 990 2014-12-01 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 2016-04-07 1 BRUCE A PAVLIK P00748405 3123680500 2014 2016-08-17 19:52:53Z ROBERT NIKSA 9801 WEST HIGGINS ROAD NO 500 ROSEMONT IL 60018 13027493 0 X N/A X 1960 IL PROVIDE HEALTH BENEFITS 4 4 0 0 0 0 0 0 8249173 7959555 179276 121627 729 810 8429178 8081992 0 0 9422451 9422683 0 0 0 0 0 628298 567483 10050749 9990166 -1621571 -1908174 9677639 7782021 151447 64187 9526192 7717834 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 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 55 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 KENNETH DIEHL TRUSTEE - ALTERNATE - PAST 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 541778 1 EMPLOYER CONTRIBUTIONS 900099 7806530 7806530 STOP LOSS REFUNDS 900099 124162 124162 PARTICIPANT CONTRIBUTIONS 900099 28863 28863 7959555 203258 203258 4863870 4945501 -81631 -81631 -81631 MISCELLANEOUS 900099 810 810 810 8081992 7959555 0 122437 9422683 354943 8091 31983 47425 78641 9897 7653 10342 FEES MANDATED BY ACA 13216 WEB CLAIMS SERVICE FEE 5292 9990166 11632 114628 479657 613585 334144 93098 31910 5326 8780039 6919009 40257 36375 9677639 7782021 151447 38437 0 25750 151447 64187 X 0 0 0 0 9526192 7717834 9526192 7717834 9677639 7782021 -1908174 99816 0 X 0 1 X 1 0 0 EMPLOYER CONTRIBUTIONS CREDIT 25750 25750 X 8134383 99816 99816 8034567 47425 47425 8081992 9942741 0 9942741 47425 47425 9990166 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 MILLER GROCER MARKET 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