2014-03-05T09:43:48-06:00 2013-11-30 320043599 LEGACY PROFESSIONALS LLP 311 S WACKER DRIVE STE 4000 CHICAGO IL 60606 990 2012-12-01 351065816 UNITED FOOD & COMM WORKERS CALUMET REGION INSURANCE FUND UNIT 8473847000 9801 WEST HIGGINS ROAD NO 500 ROSEMONT IL 60018 DAN RYAN 8473847000 2014-03-05 1 BRUCE A PAVLIK P00748405 3123680500 2012 2015-11-30 17:44:51Z X DAN RYAN 9801 WEST HIGGINS ROAD NO 500 ROSEMONT IL 60018 12496153 0 X N/A X 1960 IN PROVIDE HEALTH BENEFITS 4 4 0 0 0 0 0 0 7907931 7453334 316715 166681 71 0 8224717 7620015 0 0 7371197 7590065 0 0 0 0 0 459194 488137 7830391 8078202 394326 -458187 10596171 10645896 56135 28627 10540036 10617269 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 19 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 DAN RYAN 8473847000 9801 WEST HIGGINS ROAD ROSEMONT IL 60018 X STEVEN POWELL 3.00 X 0 0 0 SAMUEL VAN TIL 3.00 X 0 0 0 LISA CATANZARO 3.00 X 0 0 0 JEFFREY STRACK 3.00 X 0 0 0 HARRY GROW 3.00 X 0 0 0 DAVID WILKINSON 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 436038 1 EMPLOYER CONTRIBUTIONS 900099 7212524 7212524 STOP LOSS & REINSURANCE 900099 179430 179430 PARTICIPANT CONTRIBUTIONS 900099 61380 61380 7453334 264321 264321 4778498 4876138 -97640 -97640 -97640 7620015 7453334 0 166681 7590065 270077 5006 53341 54259 68728 9971 9814 8979 WEB CLAIMS SERVICE FEE 5292 MISCELLANEOUS 2670 8078202 330378 63732 704712 427017 263975 211133 39570 41906 9203669 9853843 53867 48265 10596171 10645896 38539 28627 17596 0 56135 28627 X 0 0 0 0 10540036 10617269 10540036 10617269 10596171 10645896 -458187 535420 0 X 0 1 X 1 0 0 X 8101176 535420 535420 7565756 54259 54259 7620015 8023943 0 8023943 54259 54259 8078202 DESCRIPTION OF UNCERTAIN TAX POSITIONS UNDER FIN 48: 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 WISE WAY SUPER CENTERS 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