2021-04-22T16:03:40-05:00 2020-06-30 MILLER KAPLAN ARASE LLP 600 STEWART ST STE 618 SEATTLE WA 981011261 990 2019-07-01 237017278 UFCW LOCAL 555-EMPLOYERS HEALTH TRUST % PATI PIRO-BOSLEY UFCW 8667967623 12205 SW Tualatin Rd ste 200 TUALATIN OR 97062 PATI PIRO-BOSLEY Plan Administrator 8667967623 2021-04-07 true Jeffrey Goss P00349311 2065963930 2019 2022-09-23 18:48:47Z Dan Clay 12205 SW Tualatin Rd ste 200 TUALATIN OR 97062 114440432 false X N/A X 1977 OR See Schedule O 8 8 0 0 0 0 0 0 154175535 48680019 736850 4345996 0 0 154912385 53026015 0 0 134083266 130875498 0 0 0 0 0 3027323 2547905 137110589 133423403 17801796 -80397388 238470001 160650818 33975639 31480456 204494362 129170362 X SEE SCHEDULE O false false see schedule o false false false false false false false false false false false false true true true false false false false false false false false false false false false false false false false false false false false false false false false true false false true 0 0 0 false false false false false false false false X 8 8 false true false false false false false true true false false true true true true true true false X PATI PIRO-BOSLEY 8667967623 12205 SW TUALATIN RD STE 200 TUALATIN OR 97062 X X SEAN HAMMOND TRUSTEE 1.0 0.0 X 0 0 0 JEFF ANDERSON TRUSTEE 1.0 0.0 X 0 0 0 MIKE MARSHALL TRUSTEE 1.0 0.0 X 0 0 0 BRENT BOHN TRUSTEE 1.0 0.0 X 0 0 0 FRANK JORGENSEN TRUSTEE 1.0 0.0 X 0 0 0 KYLE BRITTINGHAM TRUSTEE 1.0 0.0 X 0 0 0 SCOTT POWERS TRUSTEE 1.0 0.0 X 0 0 0 ESAI ALDAY ALTERNATE TRUSTEE 1.0 0.0 X 0 0 0 RAGINI GUPTA Alternate Trustee 1.0 0.0 X 0 0 0 TERESA POLLOCK Alternate Trustee 1.0 0.0 X 0 0 0 SHARON CARROLL ALTERNATE TRUSTEE 1.0 0.0 X 0 0 0 DAN CLAY TRUSTEE 1.0 0.0 X 0 0 0 0 0 0 0 false false false Regence Bluecross Blueshield PO Box 1271 M/S Elia PORTLAND OR 97027 PPO Provider 2124461 Zenith American Solutions 12205 SW Tualatin Rd Ste 200 TUALATIN OR 97062 Contract Admin. 3475797 Innovative Care Management Inc 12300 SE MALLARD WAY MILWAUKIE OR 97222 Claims Management 876238 Envision Pharmaceutical Services L 2181 E Aurora RD Ste 201 TWINSBURG OH 44087 Pharmacy Provider 472947 LOOMIS SAYLES 4 ORINDA WAY STE 200-A ORLANDO CA 94563 INVESTMENT ADVISORY 213763 5 0 EMPLOYER CONTRIBUTIONS 900099 40430686 40430686 EMPLOYEE CONTRIBUTIONS 900099 8249333 8249333 48680019 1156444 1156444 0 0 0 0 0 64603969 61414417 3189552 3189552 3189552 0 0 0 0 0 0 0 0 0 0 53026015 48680019 0 4345996 0 0 0 130875498 0 0 0 0 0 0 1231357 47500 45887 0 0 426124 298540 0 379716 0 0 0 0 0 10236 0 0 0 71058 PCORI FEES 37487 133423403 50891621 12176587 0 0 0 0 14625821 2127994 0 0 0 0 0 0 0 0 65566 0 0 0 172886993 146346237 0 0 0 0 0 0 0 0 238470001 160650818 357090 115655 0 0 0 0 0 0 0 0 0 0 0 0 0 0 33618549 31364801 33975639 31480456 X 0 0 0 0 204494362 129170362 204494362 129170362 238470001 160650818 -80397388 5073388 0 0 0 0 X false true X true 0 CLAIMS INCURRED BUT NOT REPORTED 7727000 ACCUMULATED ELIGIBILITY CREDITS 20726439 CLAIMS PAYABLE 2911362 31364801 X 58099403 5073388 5073388 53026015 53026015 135677151 2253748 2253748 133423403 133423403 PART X, LINE 2: Accounting principles generally accepted in the United States of America require management to evaluate tax positions taken by the Plan and recognize a tax liability if the Plan has taken a tax position that more likely than not would not be sustained upon examination by a tax authority. The Plan is subject to routine audits by taxing jurisdictions; however, there are currently no audits for any tax periods in progress. PART XII, LINE 4B DECREASE IN BENEFIT OBLIGATIONS. part i, line 1 and part iii, lines 1 and 4a: TO PROVIDE MEDICAL, VISION, DENTAL, PRESCRIPTION, SUPPLEMENTAL INCOME, LIFE AND ACCIDENTAL DEATH AND DISMEMBERSHIP BENEFITS TO PARTICIPANTS ON WHOSE BEHALF EMPLOYERS CONTRIBUTE TO THE PLAN IN ACCORDANCE WITH THEIR COLLECTIVE BARGAINING AGREEMENT. part vi, line 11b: FORM 990 WAS reviewed by THE PLAN ADMINISTRATOR PRIOR TO FILING; ANY UNUSUAL ITEMS OR ITEMS NEEDING TO BE ADDRESSED WILL BE BROUGHT TO THE TRUSTEES' ATTENTION. part vi, line 12c: TRUSTEES ARE REQUIRED TO NOTIFY THE PLAN OF ANY CHANGES IN THEIR INTERESTS THAT COULD GIVE RISE TO CONFLICTS. part vi, line 19: THE PLAN DOCUMENT, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS ARE MAINTAINED IN THE PLANS' OFFICE AND ARE AVAILABLE UPON REQUEST. part vii, section a: TRUSTEE COMPENSATION AND BENEFITS FROM RELATED TAX-EXEMPT ORGANIZATIONS IS PROPERLY REPORTED AND AVAILABLE ON THOSE ORGANIZATIONS' TAX FILINGS. false false false false false false false false false false false false false false false false false false false