2016-06-06T11:26:34-05:00 2015-11-30 320043599 LEGACY PROFESSIONALS LLP 311 S WACKER DRIVE STE 4000 CHICAGO IL 60606 990 2014-12-01 362440523 U F C W UNIONS & EMPLOYERS MIDWEST HEALTH BENEFITS FUND UFCW 8473847000 9801 WEST HIGGINS ROAD NO 500 ROSEMONT IL 60018 ROBERT NIKSA ADMINISTRATOR 8473847000 2016-06-06 1 CRAIG RESCH P00844633 3123680500 2014 2016-08-17 19:52:53Z ROBERT NIKSA 9801 WEST HIGGINS ROAD NO 500 ROSEMONT IL 60018 59369489 0 X WWW.UFCWMIDWEST.ORG X 1960 IL PROVIDE HEALTH BENEFITS 6 3 77 0 0 0 0 0 41415320 27449089 385370 725589 71309 50109 41871999 28224787 0 0 45306432 31120908 5880988 4726283 0 0 0 2293076 2002676 53480496 37849867 -11608497 -9625080 33395682 23592511 1245184 1140701 32150498 22451810 PROVIDE HEALTH BENEFITS 0 0 TO PROVIDE HEALTH CARE, DEATH AND DISABILITY BENEFITS FOR ELIGIBLE PARTICIPANTS AND THEIR DEPENDENTS. 0 0 0 0 0 0 0 0 0 1 0 0 0 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 1236 0 1 77 1 0 0 0 0 0 0 0 0 X 6 3 0 0 0 0 0 0 0 1 0 0 0 1 1 0 0 1 0 1 0 0 X DAVID MINEAU 8473847000 9801 WEST HIGGINS ROAD SUITE 500 ROSEMONT IL 60018 BRIAN JORDAN TRUSTEE 3.00 X 0 0 0 KEVIN J BECKERLE TRUSTEE 3.00 X 0 0 0 DEREK KINNEY TRUSTEE 3.00 X 0 0 0 DANIEL RYAN ASSISTANT ADMINISTRATOR 40.00 X 115398 0 69165 KENNETH R BOYD TRUSTEE 3.00 55.00 X 0 174133 21953 STEVEN M POWELL TRUSTEE 3.00 40.00 X 0 247318 20899 NANCY MAIZE PENSION DIRECTOR 40.00 X 104006 0 24264 KENNETH URZEDOWSKI TRUSTEE 3.00 40.00 X 0 128204 19202 DONALD SCHAPER TRUSTEE - PAST 3.00 X 0 0 0 ROBERT NIKSA ADMINISTRATOR 40.00 X 77699 0 25527 297103 549655 181010 2 0 1 0 BLUE CROSS BLUE SHIELD 300 EAST RANDOLPH ST CHICAGO IL 60601 PPO PROVIDER 1727898 THE SEGAL COMPANY PO BOX 4092 CHURCH STREET STATION NEW YORK NY 10261 ACTUARY 182276 MEDICAL INSURANCE CONSULTING GROUP INC 4949 N WESTERN AVENUE CHICAGO IL 60625 MEDICAL CONSULTANT 167295 LEGACY PROFESSIONALS LLP 311 SOUTH WACKER STE 4000 CHICAGO IL 60606 AUDITOR 162997 CATAMARAN 1600 MCCONNOR PARKWAY SCHAUMBURG IL 60173 PHARMACY BENEFIT MANAGER 118021 5 EMPLOYER CONTRIBUTIONS 900099 23368013 23368013 REIMB EXP UFCW MW PENSION 900099 2328174 2328174 PARTICIPANT CONTRIBUTIONS 900099 1178614 1178614 REIMB EXPS UFCW CALUMET FUND 900099 354943 354943 PRESCRIPTION DRUG REBATES 900099 219345 219345 27449089 513978 513978 31356313 31144702 211611 211611 211611 MISCELLANEOUS INCOME 900099 50109 50109 50109 28224787 27449089 0 775698 31120908 182571 3034515 710929 539176 259092 79765 123272 74633 301298 277326 77943 402280 348 35465 208712 258622 WEB CLAIMS SERVICE FEE 47628 FEES MANDATED BY ACA 43173 OTHER PERSONNEL COSTS 36233 STORAGE OF DOCUMENTS 35978 37849867 392082 350482 1668687 1365561 2902330 2253666 84109 97361 506171 249488 317794 256683 28030680 19268758 0 0 33395682 23592511 753516 622238 491668 518463 1245184 1140701 X 0 0 0 0 32150498 22451810 32150498 22451810 33395682 23592511 -9625080 -73608 0 X 0 1 X 1 0 506171 249488 256683 256683 DUE TO PARTICIPANTS OF DEFERRED COMPENSATION PLANS 206750 MAINTENANCE OF RESERVE POLICY REFUNDS 25582 DEFERRED LEASE INCENTIVE 286131 518463 X 25748372 -73608 -73608 25821980 74633 2328174 2402807 28224787 35447060 0 35447060 74633 2328174 2402807 37849867 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. PART XI, LINE 4B - OTHER ADJUSTMENTS: REIMBURSED ADMIN EXPENSE - UFCW PENSION FUND 2,328,174. PART XII, LINE 4B - OTHER ADJUSTMENTS: REIMBURSED ADMIN EXPENSE - UFCW PENSION FUND 2,328,174. X 0 1 0 DANIEL RYAN ASSISTANT ADMINISTRATOR 115398 0 0 0 0 0 59572 0 9593 0 184563 0 0 0 KENNETH R BOYD TRUSTEE 0 174133 0 0 0 0 0 6381 0 15572 0 196086 0 0 STEVEN M POWELL TRUSTEE 0 195302 0 7431 0 44585 0 2498 0 18401 0 268217 0 0 PART I, LINE 4B DAN RYAN, THE PRIOR ADMINISTRATOR AND CURRENT ASSISTANT ADMINISTRATOR, PARTICIPATES IN A DEFERRED COMPENSATION PLAN ESTABLISHED UNDER SECTION 457(F) OF THE IRS CODE. FORM 990, SCHEDULE J, PART II, COLUMN C RETIREMENT AND OTHER DEFERRED COMPENSATION INCLUDES THE INCREASE IN THE PRESENT VALUE OF A DEFINED BENEFIT PENSION PLAN FOR ROBERT NIKSA, DANIEL RYAN AND NANCY MAIZE AS DETERMINED BY THE FUND'S ACTUARY. FORM 990, SCHEDULE J, PART II, COLUMN D NON-TAXABLE BENEFITS INCLUDE THE VALUE OF HEALTH AND WELFARE PREMIUMS PAID ON BEHALF OF THE INDIVIDUAL. FORM 990, PART VI, SECTION A, LINE 8B THE PLAN DOES NOT HAVE ANY SEPARATE COMMITTEES WITH THE AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BOARD. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PROVIDED TO THE ENTIRE BOARD OF TRUSTEES FOR REVIEW AND APPROVAL BEFORE IT IS SIGNED AND FILED. FORM 990, PART VI, SECTION B, LINE 15A SALARIES ARE ANNUALLY REVIEWED AND APPROVED BY THE BOARD OF TRUSTEES. 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. FORM 990, PART VII, SECTION A IN JUNE 2014, ROBERT NIKSA WAS HIRED AS THE FULL TIME ADMINISTRATOR AND DANIEL RYAN WAS NAMED AS THE ASSISTANT ADMINISTRATOR. THE COMPENSATION REPORTED IN PART VII, AS DEFINED BY THE INSTRUCTIONS, IS THE CALENDAR YEAR 2014 COMPENSATION WHICH IS THE CALENDAR YEAR WHICH ENDED DURING THE PLAN'S FISCAL YEAR ENDED NOVEMBER 30, 2015. UNITED FOOD & COMMERICAL WORKERS & EMPRS MIDWEST PENSION FUND 9801 WEST HIGGINS ROAD ROSEMONT IL 60018 366508328 RETIREMENT BENEFITS FOR ELIGIBLE PARTICIPANTS IL 501(A) N/A 0 UNITED FOOD & COMMERICAL WORKERS LOCAL 881 CONTRIBUTING EMPLOYER 0 UNITED FOOD & COMMERICAL WORKERS LOCAL 1546 CONTRIBUTING EMPLOYER 0 UNITED FOOD & COMMERCIAL WORKERS LOCAL 536 CONTRIBUTING EMPLOYER 0 UNITED STEEL WORKERS OF AMERICA LOCAL 6787 CONTRIBUTING EMPLOYER 0 A & G LAUNDROMAT CONTRIBUTING EMPLOYER 0 ANICHINI BROS INC CONTRIBUTING EMPLOYER 0 ANTON'S FRUIT RANCH & CONTRIBUTING EMPLOYER 0 APPLE MARKET CONTRIBUTING EMPLOYER 0 ARAMARK UNIFORM SERVICES CONTRIBUTING EMPLOYER 0 ARLINGTON GOURMET MKT CONTRIBUTING EMPLOYER 0 ASCOT MEATS INC CONTRIBUTING EMPLOYER 0 ASHMANN PRESCRIPTIONS CONTRIBUTING EMPLOYER 0 ATHENA SCHOOL - CO CONTRIBUTING EMPLOYER 0 BAJA SERVICES CONTRIBUTING EMPLOYER 0 BASIC HARDWARE CENTER CONTRIBUTING EMPLOYER 0 BLUE GOOSE STORE CONTRIBUTING EMPLOYER 0 BUEDEL'S FOOD PRODUCTS CONTRIBUTING 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SERVICE INC CONTRIBUTING EMPLOYER 0 GEPPERTH'S MARKET CONTRIBUTING EMPLOYER 0 GILLMORES CORNER MARKET CONTRIBUTING EMPLOYER 0 GLENVIEW GOURMET MEATS CONTRIBUTING EMPLOYER 0 GREAT WESTERN BEEF CONTRIBUTING EMPLOYER 0 HADDAD'S MARKET CONTRIBUTING EMPLOYER 0 HAPPY FOODS INC CONTRIBUTING EMPLOYER 0 HARI LLC CONTRIBUTING EMPLOYER 0 HARMON'S FOODS CONTRIBUTING EMPLOYER 0 HOLZKOPF'S MEAT CONTRIBUTING EMPLOYER 0 HOME FURNITURE LLC CONTRIBUTING EMPLOYER 0 HONEY BAKED HAM CONTRIBUTING EMPLOYER 0 ILLINOIS FOOD RETAILERS ASSOCIATION CONTRIBUTING EMPLOYER 0 INTERNATIONAL MEAT CO INC CONTRIBUTING EMPLOYER 0 JT AMUSEMENTS LTD CONTRIBUTING EMPLOYER 0 JACK & PAT'S CERT INC CONTRIBUTING EMPLOYER 0 JERRY'S QUALITY MEATS CONTRIBUTING EMPLOYER 0 JOHNNY G'S QUALITY MEATS CONTRIBUTING EMPLOYER 0 JONDEB CORP CONTRIBUTING EMPLOYER 0 K & S WHOLESALE MEATS INC CONTRIBUTING EMPLOYER 0 KINGDOM FARMS CONTRIBUTING EMPLOYER 0 KRAMER FOODS CONTRIBUTING EMPLOYER 0 LAKE AREA UNITED WAY CONTRIBUTING EMPLOYER 0 LEGACY HEALTHCARE CONTRIBUTING EMPLOYER 0 M & K FOODS DBA SEVEN-ELEVEN CONTRIBUTING EMPLOYER 0 MARCO CONSULTING GROUP CONTRIBUTING EMPLOYER 0 MARIO'S BUTCHER SHOP CONTRIBUTING EMPLOYER 0 MAXON SHOOTERS CONTRIBUTING EMPLOYER 0 MIKE'S MEAT MARKET CONTRIBUTING EMPLOYER 0 MILLER GROCERY MARKET LLC CONTRIBUTING EMPLOYER 0 MINELLI DELI & MEATS CONTRIBUTING EMPLOYER 0 MR BEEF CONTRIBUTING EMPLOYER 0 MR CKGK INC CONTRIBUTING EMPLOYER 0 MURPHY & ASSOCIATES LTD CONTRIBUTING EMPLOYER 0 NORTHWESTERN INDIANA CONTRIBUTING EMPLOYER 0 ONE STOP FOOD & LIQUORS CONTRIBUTING EMPLOYER 0 ONE STOP PACEMAKER CONTRIBUTING EMPLOYER 0 ORCHARD PRIME MEATS CONTRIBUTING EMPLOYER 0 P & V CATERING CONTRIBUTING EMPLOYER 0 PARAMOUNT TRUCK BODY CONTRIBUTING EMPLOYER 0 PARKSHORE MARKET LTD CONTRIBUTING EMPLOYER 0 PAULINA MARKET CONTRIBUTING EMPLOYER 0 PERSONAL CHEF SERVICES CONTRIBUTING EMPLOYER 0 PIATAK MEATS CONTRIBUTING EMPLOYER 0 POTASH BROTHERS CONTRIBUTING EMPLOYER 0 PRIME'N TENDER MEATS CONTRIBUTING EMPLOYER 0 RABER PACKING CO CONTRIBUTING EMPLOYER 0 RIVERSIDE FOODS CONTRIBUTING EMPLOYER 0 ROIN'S PRODUCE CONTRIBUTING EMPLOYER 0 RUSSO OF ITALY HAIR DESIGNS CONTRIBUTING EMPLOYER 0 RUSSO WHOLESALE CONTRIBUTING EMPLOYER 0 SNN INC CONTRIBUTING EMPLOYER 0 SALEM VILLAGE NURSING HM CONTRIBUTING EMPLOYER 0 SAURO & ASSOC INC CONTRIBUTING EMPLOYER 0 SCHWEGEL'S MARKET CONTRIBUTING EMPLOYER 0 SHOELESS JOE'S CONTRIBUTING EMPLOYER 0 SODEXO INC CONTRIBUTING EMPLOYER 0 STEINBACH MEATS CONTRIBUTING EMPLOYER 0 STRACK-ULTRA CONTRIBUTING EMPLOYER 0 SUNSET FOOD MART CONTRIBUTING EMPLOYER 0 SUPERVALU CONTRIBUTING EMPLOYER 0 SV CARE SOUTHVIEW CONTRIBUTING EMPLOYER 0 SYMPHONY HEALTHCARE CONTRIBUTING EMPLOYER 0 TED'S AUTO CLINIC CONTRIBUTING EMPLOYER 0 TERRACE NURSING CONTRIBUTING EMPLOYER 0 THE KROGER COMPANY CONTRIBUTING EMPLOYER 0 TRANSPORT PRODUCTION SYSTEMS CONTRIBUTING EMPLOYER 0 TREASURE ISLAND CONTRIBUTING EMPLOYER 0 TRISTATE SECURITY OF AMER CONTRIBUTING EMPLOYER 0 WELCH'S STOP & SHOP CONTRIBUTING EMPLOYER 0 WHEATON MEAT CO CONTRIBUTING EMPLOYER 0 WINSTON'S SAUSAGE CONTRIBUTING EMPLOYER 0 YESTER YEARS MEAT SHOPPE CONTRIBUTING EMPLOYER 0 ZENITH AMERICAN SOLUTIONS CONTRIBUTING EMPLOYER 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 1 UNITED FOOD AND COMMERICAL WORKERS UNIONS & EMPLOYERS MIDWEST PENSION FUND N 456029 UNITED FOOD AND COMMERICAL WORKERS UNIONS & EMPLOYERS MIDWEST PENSION FUND O 1872145 UNITED FOOD AND COMMERICAL WORKERS UNIONS & EMPLOYERS MIDWEST PENSION FUND Q 2850708