2016-02-02T10:34:06-06:00 2015-04-30 320043599 LEGACY PROFESSIONALS LLP 311 S WACKER DRIVE STE 4000 CHICAGO IL 60606 990 2014-05-01 846044454 ROCKY MOUNTAIN UFCW UNIONS & EMPLOYERS HEALTH BENEFIT FUND ROCK 3034301118 5511 W 56TH AVE NO 250 ARVADA CO 800022815 STEVE DICROCE TRUSTEE 3034301118 2016-02-02 1 TIMOTHY CIBULKA P00841100 3123680500 2014 2016-04-25 22:37:26Z STEVE DICROCE 5511 W 56TH AVE NO 250 ARVADA CO 800022815 120637706 0 X N/A X 1965 CO PROVIDE HEALTH BENEFITS 6 3 0 0 0 0 0 0 122155144 118605774 25277 18238 8396 7669 122188817 118631681 0 0 101721271 107687828 0 0 0 0 0 8041212 9871387 109762483 117559215 12426334 1072466 43553270 44503097 621006 508820 42932264 43994277 TO PROVIDE HEALTH BENEFITS TO THE ELIGIBLE PARTICIPANTS AND DEPENDENTS OF ROCKY MOUNTAIN UFCW & EMPLOYERS HEALTH BENEFIT PLAN. 0 0 TO PROVIDE HEALTH, LIFE, ACCIDENTAL DEATH AND DISMEMBERMENT, DENTAL, VISION, PRESCRIPTION AND TEMPORARY DISABILITY BENEFITS TO ELIGIBLE PARTICIPANTS AND 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 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 X 6 3 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X ZENITH AMERICAN SOLUTIONS 3034301118 5511 W 56TH AVE NO 250 ARVADA CO 80002 STEVE DICROCE TRUSTEE 1.00 X 0 0 0 BRYAN SMITH TRUSTEE 1.00 X 0 0 0 DANNY MA TRUSTEE 1.00 X 0 0 0 KIM CORDOVA TRUSTEE 1.00 45.00 X 0 173889 12901 KEVIN SCHNEIDER TRUSTEE 1.00 45.00 X 0 153565 12901 NATHANIEL BERNSTEIN TRUSTEE 1.00 45.00 X 0 147810 12901 0 475264 38703 0 0 1 0 CIGNA 900 COTTAGE GROVE ROAD HARTFORD CT 06152 PPO ACCESS AND ADMIN FEES 4912372 ZENITH AMERICAN SOLUTIONS 5511 W 56TH AVE STE 250 ARVADA CO 80002 THIRD PARTY ADMINISTRATOR 1909201 DELTA DENTAL 4582 S ULSTER STREET STE 800 DENVER CO 80237 BENEFIT ADMIN FEES 335691 REINHART BOERNER VAN DEURAN SC 1000 N WATER ST STE 1700 MILWAUKEE WI 53202 LEGAL SERVICES 296747 THE SEGAL COMPANY 101 N WACKER DRIVE STE 500 CHICAGO IL 60606 ACTUARIAL SERVICES 289495 8 EMPLOYER CONTRIBUTIONS 900099 103566961 103566961 PARTICIPANT CONTRIBUTIONS 900099 12897130 12897130 PRESCRIPTION REBATES 900099 1312702 1312702 MEDICARE PT. D RETIREE DRUG SUBSI 900099 574135 574135 BENEFITS CLAIMS REFUND 900099 254846 254846 118605774 24263 24263 2000000 2006025 -6025 -6025 -6025 MISCELLANEOUS INCOME 900099 7669 7669 7669 118631681 118605774 0 25907 107687828 1831826 356076 80048 319 6289039 345378 22772 47227 FEES MANDATED BY ACA 898702 117559215 8029119 6132235 21912122 27550437 10335506 9518532 41848 3276523 1260045 43553270 44503097 507331 401887 113675 105200 0 1733 621006 508820 X 0 0 0 0 42932264 43994277 42932264 43994277 43553270 44503097 1072466 -10453 0 X X 0 1 X 1 0 0 DUE TO RELATED ORGANIZATIONS 1733 1733 X 109062778 0 109062778 9568903 9568903 118631681 108348615 0 108348615 9210600 9210600 117559215 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: RETIREE PLAN - EMPLOYER CONTRIBUTIONS 2,824,752. RETIREE PLAN - INVESTMENT INTEREST 21,793. RETIREE PLAN - RETIREE CONTRIBUTIONS 5,727,823. RETIREE PLAN - PRESCRIPTION REBATES 426,425. RETIREE PLAN - MEDICARE PT. D RETIREE DRUG SUBSIDIES 574,135. RETIREE PLAN - REALIZED LOSS ON INVESTMENT SOLD -6,025. PART XII, LINE 4B - OTHER ADJUSTMENTS: RETIREE PLAN - MEDICAL BENEFITS 2,609,430. RETIREE PLAN - PRESCRIPTION BENEFITS 3,939,729. RETIREE PLAN - MEDICAL PREMIUMS 2,016,311. RETIREE PLAN - PPO FEES & PROVIDER FEES 289,978. RETIREE PLAN - ADMINISTRATIVE EXPENSES 276,405. RETIREE PLAN - INVESTMENT FEES 319. RETIREE PLAN - FEES MANDATED BY ACA 34,105. RETIREE PLAN - HMO PREMIUMS 44,323. 0 0 0 KIM CORDOVA TRUSTEE 0 172394 0 0 0 1495 0 2995 0 9906 0 186790 0 0 KEVIN SCHNEIDER TRUSTEE 0 153226 0 0 0 339 0 2995 0 9906 0 166466 0 0 NATHANIEL BERNSTEIN TRUSTEE 0 146553 0 0 0 1257 0 2995 0 9906 0 160711 0 0 FORM 990, PART VI, SECTION A, LINE 3 THE BOARD OF TRUSTEES HAS DELEGATED THE RECORD KEEPING AND DAY TO DAY ADMINISRATION OF THE PLAN TO ZENITH AMERICAN SOLUTIONS. FORM 990, PART VI, SECTION B, LINE 11 THE FORM 990 IS PROVIDED TO THE ENTIRE BOARD OF TRUSTEES AND PLAN ADMINISTRATOR PRIOR TO FILING. AFTER THE BOARDS REVIEW, THE FORM IS APPROVED AND FILED. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF TRUSTEES ARE REQUIRED TO DISCLOSE ANY NONADHERANCE TO THE ADOPTED POLICY. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST AT THE PLAN OFFICE. FINANCIAL STATEMENTS: THE ROCKY MOUNTAIN UFCW UNIONS AND EMPLOYERS HEALTH BENEFIT FUND - ACTIVES AND ROCKY MOUNTAIN UFCW UNIONS AND EMPLOYERS HEALTH BENEFIT FUND - RETIREE OPERATES UNDER ONE TRUST AGREEMENT. EACH PLAN ISSUES SEPARATE AUDITED FINANCIAL STATEMENTS. BOTH PLANS ARE REPORTED ON THIS FORM 990 ON A CONSOLIDATED BASIS. FORM 990, PART XI, LINE 5: THE $10,453 NET UNREALIZED LOSSES PERTAINS TO THE ROCKY MOUNTAIN UFCW UNIONS AND EMPLOYERS HEALTH BENEFIT FUND - RETIREE. SEE NOTE IN SCHEDULE O, PART XII, LINE 2B FOR FURTHER EXPLAINATION. ROCKY MOUNTAIN UFCW UNIONS AND EMPLOYERS PENSION PLAN 5511 W 56TH AVE SUITE 250 ARVADA CO 80002 846045986 PROVIDE PENSION BENEFITS TO ELIGIBLE PARTICIPANTS AND BENEFICIARIES CO 401(A) N/A 0 DENVER AREA MEAT CUTTERS AND EMPLOYERS PENSION PLAN 5511 W 56TH AVE SUITE 250 ARVADA CO 80002 846097461 PROVIDE PENSION BENEFITS TO ELIGIBLE PARTICIPANTS AND BENEFICIARIES CO 401(A) N/A 0 UNITED FOOD AND COMMERICAL WORKERS INTERNATIONAL UNION 7R LOCAL CONTRIBUTING EMPLOYER 0 ALBERTSONS CONTRIBUTING EMPLOYER 0 ALMAGNO FREELANCE CONTRIBUTING EMPLOYER 0 DARLING INTERNATIONAL CONTRIBUTING EMPLOYER 0 DEBONAIRE HAIR CONTRIBUTING EMPLOYER 0 DENVER PROCESSING (KS - MEAT PLANT) CONTRIBUTING EMPLOYER 0 GARY & CORI LEETE CONTRIBUTING EMPLOYER 0 IMAGES - A LIZZI CONTRIBUTING EMPLOYER 0 KING SOOPERS CONTRIBUTING EMPLOYER 0 MOSHO'S BARBER SERVICE CONTRIBUTING EMPLOYER 0 THE PERFECT TOUCH CONTRIBUTING EMPLOYER 0 SAFEWAY CONTRIBUTING EMPLOYER 0 ZENITH AMERICAN SOLUTIONS CONTRIBUTING EMPLOYER 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ROCKY MOUNTAIN UFCW UNIONS & EMPLOYERS PENSION PLAN S 3132435 COST DENVER AREA MEAT CUTTERS & EMPLOYERS PENSION PLAN S 1234230 COST