2015-03-31T12:12:44-05:00 2014-11-30 320043599 LEGACY PROFESSIONALS LLP 311 S WACKER DRIVE STE 4000 CHICAGO IL 60606 990 2013-12-01 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 2015-03-31 1 BRUCE A PAVLIK P00748405 3123680500 2013 2016-02-25 16:41:14Z ROBERT NIKSA 9801 WEST HIGGINS ROAD NO 500 ROSEMONT IL 60018 15521277 0 X N/A X 1960 IN PROVIDE HEALTH BENEFITS 4 4 0 0 0 0 0 0 7453334 8249173 166681 179276 0 729 7620015 8429178 0 0 7590065 9422451 0 0 0 0 0 488137 628298 8078202 10050749 -458187 -1621571 10645896 9677639 28627 151447 10617269 9526192 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 0 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 36 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 DAVID WILKINSON TRUSTEE - ALTERNATE - PAST 3.00 X 0 0 0 KENNETH DIEHL 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 458462 1 EMPLOYER CONTRIBUTIONS 900099 7826149 7826149 STOP LOSS & REINSURANCE 900099 393960 393960 PARTICIPANT CONTRIBUTIONS 900099 29064 29064 8249173 239340 239340 7032035 7092099 -60064 -60064 -60064 MISCELLANEOUS 900099 729 729 729 8429178 8249173 0 180005 9422451 338204 4331 40881 48628 61466 11273 837 9334 FEES MANDATED BY ACA 107597 WEB CLAIMS SERVICE FEE 5292 MISCELLANEOUS 455 10050749 63732 11632 427017 479657 211133 334144 41906 31910 9853843 8780039 48265 40257 10645896 9677639 28627 151447 28627 151447 X 0 0 0 0 10617269 9526192 10617269 9526192 10645896 9677639 -1621571 530494 0 X 0 1 X 1 0 0 X 8911044 530494 530494 8380550 48628 48628 8429178 10002121 0 10002121 48628 48628 10050749 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