2013-11-05T10:05:11-06:00 2012-12-31 320043599 LEGACY PROFESSIONALS LLP 222 INDIANAPOLIS BOULEVARD SCHERERVILLE IN 46375 990 2012-01-01 366599036 IRONWORKERS TRI-STATE WELFARE PLAN IRON 6309603322 18861 90TH AVENUE NO A MOKENA IL 60448 BRIAN DISKIN 6309603322 2013-11-05 1 RENEE BERG-SPECK P00201492 3123680500 2012 2016-03-07 17:11:31Z X BRIAN DISKIN 18861 90TH AVENUE NO A MOKENA IL 60448 19943954 0 X N/A X 1957 IL PROVIDE HEALTH BENEFITS 12 6 24 0 0 0 0 0 13850054 17204679 936788 1317749 1439 1473 14788281 18523901 0 0 12353518 13443196 0 0 0 0 0 1143845 1257977 13497363 14701173 1290918 3822728 35428409 40923034 321967 376765 35106442 40546269 TO PROVIDE HEALTH BENEFITS 0 0 TO PROVIDE HEALTH & WELFARE BENEFITS, INCLUDING MEDICAL, DENTAL, VISION, DISABILITY, PRESCRIPTION DRUG AND DEATH BENEFIT COVERAGE FOR ELIGIBLE PARTICIPANTS AND THEIR BENEFICIARIES. 0 0 0 0 0 0 0 0 0 0 1 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 1 322 0 1 24 1 0 0 0 0 0 0 0 0 0 0 X 12 6 0 1 0 0 0 0 0 1 0 0 0 1 1 0 0 0 1 0 0 0 X ZENITH AMERICAN SOLUTIONS 7084749902 18861 9OTH AVENUE SUITE A MOKENA IL 60448 MIKE WILCHER 2.00 40.00 X 0 64718 38782 BRIAN STANLEY 2.00 40.00 X 0 97508 60083 BRIAN DISKIN 2.00 40.00 X 0 87929 40428 DANIEL AUSSEM 2.00 X 0 0 0 JACK KECK 2.00 40.00 X 0 126158 86339 HOWARD NORBERG 2.00 40.00 X 0 153484 111916 DANA OAKS 2.00 X 0 0 0 STUART BROEREN 2.00 X 0 0 0 RICHARD P CASEY 2.00 X 0 0 0 KENNETH KOBUS 2.00 40.00 X 0 99437 78088 TIM BAUGH 2.00 X 0 0 0 MICHAEL TESTA 2.00 X 0 0 0 0 629234 415636 0 0 1 0 THE SEGAL CO 101 NORTH WACKER DRIVE SUITE 500 CHICAGO IL 60606 FUND CONSULTANT 471203 BLUE CROSS BLUE SHIELD 300 EAST RANDOLPH STREET CHICAGO IL 60601 CLAIMS PROCESSOR 453629 ZENITH AMERICAN SOLUTIONS 18861 90TH AVENUE SUITE A MOKENA IL 60447 THIRD PARTY ADMINISTRATOR 336871 3 EMPLOYER CONTRIBUTIONS 900099 15068783 15068783 PARTICIPANT CONTRIBUTIONS 900099 893931 893931 STOP-LOSS INSURANCE PROCEEDS 900099 803025 803025 SUBROGATION INCOME 900099 206551 206551 PRESCRIPTION DRUG REBATE 900099 204737 204737 27652 27652 17204679 1226169 1226169 1511633 1420053 91580 91580 91580 MISCELLANEOUS 900099 1473 1473 1473 18523901 17204679 0 1319222 13443196 59173 96238 74503 711404 54374 10911 25080 23557 DISEASE MANAGEMENT 84717 COLLECTOR EXPENSE 77041 UTILIZATION REVIEW EXPE 39044 DUES & SUBSCRIPTIONS 1935 14701173 2320777 4434998 2057682 2588434 26122 16426 26704678 27743335 4319150 6139841 35428409 40923034 309476 376765 12491 0 321967 376765 X 0 0 0 0 35106442 40546269 35106442 40546269 35428409 40923034 3822728 1617099 0 X 0 1 X 1 0 0 ULLICO DIVERSIFIED INTERNATIONAL EQUITY FUND 1453130 F AMERICAN STRATEGIC VALUE REALTY FUND 3201832 F INVESCO INSTITUTIONAL TRUST BALANCED RISK ALLOCATION FUND 1484879 F 6139841 X 20091497 1617099 1617099 18474398 49503 49503 18523901 14651670 0 14651670 49503 49503 14701173 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. 0 0 0 BRIAN STANLEY 0 97508 0 0 0 0 0 58407 0 1676 0 157591 0 0 JACK KECK 0 126158 0 0 0 0 0 32697 0 53642 0 212497 0 0 HOWARD NORBERG 0 153484 0 0 0 0 0 86259 0 25657 0 265400 0 0 KENNETH KOBUS 0 99437 0 0 0 0 0 57262 0 20826 0 177525 0 0 FORM 990, PART VI, SECTION A, LINE 3 ALTHOUGH THE TRUSTEES RETAIN THE ULTIMATE RESPONSIBILITY, THEY HAVE DELEGATED THE DAY TO DAY MANAGEMENT DUTIES TO ZENITH AMERICAN SOLUTIONS, AS THIRD PARTY ADMINISTRATOR OF THE FUND. FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION HAS NO COMMITTEES WITH 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 PRIOR TO FILING. AFTER THE BOARDS THROUGH REVIEW, THE FORM IS APPROVED AND FILED. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST AT THE FUND OFFICE. 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