2012-11-09T17:48:23-06:00 2011-12-31 300702322 HEMMING MORSE CPA'S AND CONSULTANTS 160 SPEAR STREET SUITE 1900 SAN FRANCISCO CA 94105 990 2011-01-01 946078804 UFCW & EMPLOYERS BENEFIT TRUST UFCW 9257467530 1277 TREAT BOULEVARD 10TH FLOOR WALNUT CREEK CA 94597 RICK A SILVA 9257467530 2012-11-09 1 P00739466 4158364000 2011 2016-02-24 21:20:13Z RICK A SILVA 1277 TREAT BOULEVARD 10TH FLOOR WALNUT CREEK CA 94597 909993370 0 X N/A X 1962 CA TO PROVIDE HEALTH AND WELFARE BENEFITS TO ELIGIBLE PARTICIPANTS. 13 13 0 0 0 0 0 0 470768034 512070088 3576079 1379887 12462519 21960219 486806632 535410194 0 0 547101315 522424333 0 0 0 0 0 35082942 36364876 582184257 558789209 -95377625 -23379015 328995686 280170224 152673392 128404933 176322294 151765291 NONE 0 0 TO PROVIDE HEALTH AND WELFARE BENEFITS TO ELIGIBLE PARTICIPANTS COVERED UNDER THE COLLECTIVE BARGAINING AGREEMENTS BETWEEN THE UNION AND THE EMPLOYERS. 0 0 0 0 0 0 0 0 0 0 1 0 1 1 0 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 0 1 5138 0 0 0 0 0 0 0 0 0 0 0 0 X 13 13 0 1 0 0 0 0 0 1 1 0 0 1 1 0 0 1 1 0 0 0 X ROBERT WEST 9257467530 1277 TREAT BLVD 10TH FLOOR WALNUT CREEK CA 94597 X JASON BERGGREN 5.00 X 0 0 0 JAMES V MORGAN 5.00 X 0 0 0 TROY DININ 5.00 X 0 0 0 W ROBERT VALLON 5.00 X 0 0 0 BRENT BOHN 5.00 X 0 0 0 JERRY HUNSUCKER 5.00 X 0 0 0 JACQUES S LOVEALL 5.00 X 0 0 0 SHERYL PERCELL 5.00 X 0 0 0 MICHAEL A BORSTEL 5.00 X 0 0 0 KIRK L VOGT 5.00 X 0 0 0 JOSEPH AMBROSI 5.00 X 0 0 0 MICHAEL SHARPE 5.00 X 0 0 0 TERRY GONZALES 5.00 X 0 0 0 0 0 0 0 0 0 0 UFCW GROUP ADMINISTRATION LLC 1277 TREAT BOULEVARD 10TH FLOOR WALNUT CREEK CA 94597 CONTRACT ADMINISTRATOR 18216504 BLUE SHIELD OF CALIFORNIA 2170 TOWNE CENTER PLACE ANAHEIM CA 92806 HEALTHCARE ADMINISTRATION 7414273 MEDEXPERT INTERNATIONAL INC 1300 HANCOCK STREET REDWOOD CITY CA 94063 HEALTHCARE ADMINISTRATION 1520041 INFORMED RX INC 2441 WARRENVILLE ROAD SUITE 610 LISLE IL 60532 HEALTHCARE ADMINISTRATION 1199424 DELTA DENTAL 100 FIRST STREET SAN FRANCISCO CA 94105 DENTAL ADMINISTRATION 911798 15 EMPLOYER CONTRIBUTIONS 900099 490918220 490918220 PARTICIPANT CONTRIBUTN 900099 21095299 21095299 COBRA SUBSIDY 900099 56569 56569 512070088 4889454 4889454 371073609 374583176 -3509567 -3509567 -3509567 EARLY RETIREE REINSURA 900099 8825664 8825664 MEDICARE PART D 900099 7030547 7030547 PRESCRIPTION DRUG REBA 900099 5453106 5453106 650902 650902 21960219 535410194 530520740 0 4889454 522424333 18195987 969447 675461 350852 182554 53295 15629 350900 HEALTHCARE ADMINISTRATI 13259640 ACTUARIAL CONSULTANTS 1082123 UNION LOCAL ADMINISTRAT 617047 COMMUNICATION SERVICES 588339 23602 558789209 53787107 38555983 41314753 44858291 77329866 128036481 141263823 49725952 15300137 18993517 328995686 280170224 409365 28233 152264027 128376700 152673392 128404933 X 0 0 0 0 176322294 151765291 176322294 151765291 328995686 280170224 X -23379015 -1177988 X X 0 1 1 X 0 0 103-12 ENTITY 49725952 F 49725952 ACCRUED INTEREST 399143 CASH COLLATERAL FOR SECURITES ON LOAN 6170916 PREPAID INSURANCE 194228 REFUND, REBATES & SUBSIDIES 12229230 18993517 GROUP INSURANCE PREMIUMS PAYABLE 20464872 SELF-FUNDED BENEFIT CLAIMS PAYABLE 62937406 CLAIMS INCURRED BUT NOT REPORTED 38040000 LIABILITY TO RETURN COLLATERAL FOR SECURITIES ON LOAN 6168005 DUE TO OTHER TRUST FUNDS 766417 128376700 535410194 558789209 -23379015 -1177988 -1177988 -24557003 535410194 0 535410194 0 535410194 558789209 0 558789209 0 558789209 FORM 990, PART XI, LINE 2C THE TRUST FUND HAS A SPECIFIC PROCEDURE IN PLACE FOR THIS NEW DISCLOSURE REQUIREMENT ON THE SCHEDULE R. THE ADMINISTRATOR HAS SENT OUT A QUESTIONNAIRE TO OBTAIN THE REQUIRED INFORMATION FROM THE CONTRIBUTING EMPLOYERS. THE ABOVE INFORMATION REPRESENTS WHAT THE TRUST FUND HAS RECEIVED TO DATE. FORM 990, PART VI, SECTION A, LINE 3 THE ORGANIZATION DELEGATES CONTROL OF MANAGEMENT DUTIES CUSTOMARILY PERFORMED BY OR UNDER THE DIRECT SUPERVISION OF THE OFFICERS, DIRECTORS, TRUSTEES, OR KEY EMPLOYEES TO THE CONTRACT ADMINISTRATOR. FORM 990, PART VI, SECTION B, LINE 11 THE BOARD VOTES TO GIVE AUTHORITY TO CHAIR AND SECRETARY PRIOR TO SUBMISSION, WITH THEM REVIEWING AFTERWARDS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC, UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -1,177,988. FORM 990, PART XI, LINE 2C THE BOARD OF TRUSTEES ASSUMES RESPONSIBILITY FOR OVERSEEING THE AUDIT OF THE ORGANIZATION'S FINANCIAL STATEMENTS AND FOR SELECTING THE INDEPENDENT AUDITOR. 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