2011-04-08T12:56:18-05:00 2010-05-31 BAUMAN ASSOCIATES LTD PO BOX 1225 EAU CLAIRE WI 547021225 990 2009-06-01 396095127 Fox Valley Sheet Metal HEALTH FUND CO BENEFIT PLAN ADMINISTRATION FOXV 4145773700 ONE PARK PLAZA 11270 WEST PARK PLACE No 950 MILWAUKEE WI 532243632 NICHOLAS LIESCH 4145773700 2011-04-01 GREGORY D MLEZIVA CPA 7158342001 2009 2016-02-24 21:20:13Z X NICHOLAS LIESCH ONE PARK PLAZA 11270 WEST PARK PLACE No 95 MILWAUKEE WI 532243632 6962949 0 X N/A X 1981 WI TO PROVIDE WELFARE BENEFITS SUCH AS LIFE INSURANCE, ACCIDENTAL DEATH AND DISMEMBERMENT, LOSS OF TIME, DISABILITY, DENTAL, VISION, HOSPITAL, AND SURGICAL BENEFITS FOR UNION MEMBERS AND THEIR SPOUSES AND/OR DEPENDENTS. 6 6 0 0 0 0 0 7851706 6631415 382916 331534 0 8234622 6962949 0 6845934 7272222 0 0 0 491857 460230 7337791 7732452 896831 -769503 10123293 9665846 3485012 2865200 6638281 6800646 TO PROVIDE WELFARE BENEFITS, SUCH AS LIFE INSURANCE, ACCIDENTAL DEATH AND DISMEMBERMENT, LOSS OF TIME, DISABILITY, DENTAL, VISION, HOSPITAL, AND SURGICAL BENEFITS FOR UNION MEMBERS AND THEIR SPOUSES AND/OR DEPENDENTS. 0 0 THE WELFARE FUND IS A NON-CONTRIBUTORY PLAN COVERING ALL MEMBERS OF THE FOX VALLEY SHEET METAL LOCAL #18. THE PLAN PROVIDES WELFARE BENEFITS SUCH AS LIFE INSURANCE, ACCIDENTAL DEATH OR DISMEMBERMENT, LOSS OF TIME, DISABILITY, DENTAL, VISION, HOSPITAL, AND SURGICAL BENEFITS. 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 0 0 0 1 4 0 1 0 0 0 0 0 0 6 6 0 0 0 0 0 0 0 1 1 1 0 0 1 1 1 1 1 0 0 0 X BENEFIT PLAN ADMINISTRATION 4145773700 ONE PARK PLAZA 11270 WEST PARK MILWAUKEE WI 532243632 X NICHOLAS LIESCH 1.00 X X 0 0 0 CHARLES SCHUSTER 1.00 X X 0 0 0 PATRICK LANDGRAF 1.00 X 0 0 0 PAUL HANSEN 1.00 X 0 0 0 PHIL STEINHOFER 1.00 X 0 0 0 DAVID SEITZ 1.00 X 0 0 0 0 0 0 0 0 0 0 CAREMARK PO BOX 847830 DALLAS TX 75284 PRESCRIPTION DRUG PROVIDER 833849 RELIASTAR LIFE INSURANCE COMPANY 3702 PAYSPHERE CIRCLE CHICAGO IL 60674 STOP-LOSS AND LIFE AND ACCIDENTAL DEATH 649895 ZENITH ADMINISTRATORS 18861 90TH AVENUE SUITE A MOKENA IL 60448 THIRD PARTY ADMINISTRATOR 152286 3 EMPLOYER CONTRIBUTIONS 900099 5479324 5479324 STOP-LOSS REIMBURSEMEN 900099 623988 623988 PARTICIPANT CONTRIBUTI 900099 405631 405631 SUBROGATION 900099 86847 86847 Cobra Subsidy Reimburs 900099 20190 20190 15435 15435 6631415 331534 331534 6962949 6631415 0 331534 7272222 48751 22489 214128 5643 PPO SERVICE ADMINISTRAT 74495 MISCELLANEOUS EXPENSES 50992 PAYMENTS TO LOCALS 23392 FICA PAID ON DISABILITY 13010 BANK FEES 7145 185 7732452 2836223 1548978 63286 59389 6496659 7419777 727125 637702 10123293 9665846 765012 77200 2720000 2788000 3485012 2865200 X 0 0 0 0 6638281 6800646 6638281 6800646 10123293 9665846 X 0 1 1 X 0 0 CONTRIBUTIONS RECEIVABLE 532928 STOP-LOSS RECEIVABLE 78204 OTHER RECEIVABLES 26570 637702 ESTIMATED LIABILITY FOR FUTURE BENEFITS 2332000 Health Claims Payable and Claims IBNR 456000 2788000 6962949 7732452 -769503 319468 612400 931868 162365 7282417 319468 319468 6962949 0 6962949 7732452 0 7732452 0 7732452 Part XI, Line 8 - Other Adjustments: CHANGE IN ESTIMATED LIABILITY FOR FUTURE BENEFITS: 388000. INCREASE (DECREASE) IN IBNR: 224400. Form 990, Part VI, Section B, line 11 THE FUND'S ATTORNEY REVIEWS FORM 990 BEFORE IT IS FILED. THE CHAIRMAN OF THE BOARD OF TRUSTEES SIGNS FORM 990 ONCE IT HAS BEEN REVIEWED BY THE ATTORNEY. Form 990, Part VI, Section B, line 12c THE TRUSTEES ARE REQUIRED TO DISCLOSE ANY CONFLICTS OF INTEREST IMMEDIATELY UPON DISCOVERY. EACH TRUSTEE HAS SIGNED AN AGREEMENT STATING THAT HE WILL ACT IN ACCORDANCE WITH THE TRUST AGREEMENT. Form 990, Part VI, Section C, line 19 DOCUMENTATION IS AVAILABLE UPON REQUEST BY CONTACTING THE FUND OR THE FUND'S ADMINISTRATOR. Form 990, Part VII Contact Addresses for Officers, Directors, Etc NICHOLAS LIESCH - 2901 WELHOUSE DRIVE, KAUKAUNA, WI 54130-3541. CHARLES SCHUSTER - 51 WEST FERNAU AVENUE, OSHKOSH, WI 54901. PATRICK LANDGRAF - 5425 WEST VLIET STREET, MILWAUKEE, WI 53208. PAUL HANSEN - 625 SAINT MARY'S STREET, DE PERE, WI 54115-1069. PHIL STEINHOFER - P.O. BOX 109077, GREEN BAY, WI 54307. DAVID SEITZ - 3315 NORTH BALLARD ROAD, SUITE D, APPLETON, WI 54911-8988. FORM 990, PART XI, LINE 2C: NO CHANGES HAVE BEEN MADE SINCE PRIOR YEAR.