2019-02-28T13:59:12-06:00 2018-04-30 320043599 LEGACY PROFESSIONALS LLP 4 WESTBROOK CORPORATE CTR 700 WESTCHESTER IL 60154 990 2017-05-01 846044454 ROCKY MOUNTAIN UFCW UNIONS & EMPLOYERS HEALTH BENEFIT FUND ROCK 3034301118 5511 W 56TH AVE NO 250 ARVADA CO 800022815 STEVE DICROCE TRUSTEE 3034301118 2019-02-28 1 BRUCE PAVLIK P00748405 3123680500 12.235.239.120 2019-02-28 13:59:40 CS P 6880C95823272E60E39D273128B3ACEFC4B4081D DBF743AF1216C3B70D6C9C598EE47CA4DBC4F1E6 2017 2019-02-21 02:37:17Z STEVE DICROCE 5511 W 56TH AVE NO 250 ARVADA CO 800022815 123210688 0 X N/A X 1965 CO PROVIDE HEALTH BENEFITS 8 4 0 0 0 0 0 0 121140907 122823204 24474 325265 101689 62219 121267070 123210688 0 0 111406082 111003225 0 0 0 0 0 9248353 8981929 120654435 119985154 612635 3225534 47684591 50511678 967876 569429 46716715 49942249 TO PROVIDE HEALTH BENEFITS TO THE ELIGIBLE PARTICIPANTS AND DEPENDENTS OF ROCKY MOUNTAIN UFCW & EMPLOYERS HEALTH BENEFIT PLAN. 0 0 TO PROVIDE HEALTH, LIFE, ACCIDENTAL DEATH AND DISMEMBERMENT, DENTAL, VISION, PRESCRIPTION AND TEMPORARY DISABILITY BENEFITS TO ELIGIBLE PARTICIPANTS AND 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 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 X 8 4 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X ZENITH AMERICAN SOLUTIONS 3034301118 5511 W 56TH AVE NO 250 ARVADA CO 80002 STEVE DICROCE TRUSTEE 1.00 X 0 0 0 BOB MCLAUCHLIN TRUSTEE - NEW 1.00 X 0 0 0 DANNY MA TRUSTEE 1.00 X 0 0 0 KIM CORDOVA TRUSTEE 1.00 45.00 X 0 188852 12090 KEVIN SCHNEIDER TRUSTEE 1.00 45.00 X 0 167082 11639 NATHANIEL BERNSTEIN TRUSTEE 1.00 45.00 X 0 160375 11639 LEROY WESTMORELAND TRUSTEE - NEW 1.00 X 0 0 0 MARTIN GARCIA TRUSTEE - NEW 1.00 45.00 X 0 150987 11639 BRYAN SMITH TRUSTEE - PAST 1.00 X 0 0 0 0 667296 47007 0 0 1 0 CIGNA 900 COTTAGE GROVE ROAD HARTFORD CT 06152 PPO ACCESS AND ADMIN FEES 4476436 ZENITH AMERICAN SOLUTIONS 5511 W 56TH AVE STE 250 ARVADA CO 80002 THIRD PARTY ADMINISTRATOR 2292696 DELTA DENTAL 4582 S ULSTER STREET STE 800 DENVER CO 80237 DENTAL BENEFIT ADMIN FEES 313527 REINHART BOERNER VAN DEURAN SC 1000 N WATER ST STE 1700 MILWAUKEE WI 53202 LEGAL SERVICES 254682 MINES & ASSOCIATES 10367 CENTENNIAL RD 100 LITTLETON CO 80127 MENTAL HEALTH ADMIN FEES 188331 7 EMPLOYER CONTRIBUTIONS 900099 106327818 106327818 PARTICIPANT CONTRIBUTIONS 900099 12163978 12163978 PRESCRIPTION REBATES 900099 3854623 3854623 MEDICARE PT. D RETIREE DRUG SUBSI 900099 476785 476785 122823204 325265 325265 COMMISSION CREDITS 900099 53138 53138 MISCELLANEOUS INCOME 900099 9081 9081 62219 123210688 122823204 0 387484 111003225 2015195 408800 109139 5990526 354261 17531 51303 FEES MANDATED BY ACA 35174 119985154 4238465 1967064 33113517 38742268 10283497 9751690 49112 50656 47684591 50511678 213628 138499 449495 430930 304753 0 967876 569429 X 0 0 0 0 46716715 49942249 46716715 49942249 47684591 50511678 3225534 0 X X 0 1 X 1 0 0 X 113560313 0 113560313 9650375 9650375 123210688 110132971 0 110132971 9852183 9852183 119985154 PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE THE PLAN TO EVALUATE TAX POSITIONS TAKEN BY THE PLAN AND RECOGNIZE A TAX LIABILITY IF THE PLAN HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY TAX AUTHORITIES. THE PLAN IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. PART XI, LINE 4B - OTHER ADJUSTMENTS: RETIREE PLAN - EMPLOYER CONTRIBUTIONS 2,793,453. RETIREE PLAN - INVESTMENT INTEREST 28,415. RETIREE PLAN - RETIREE CONTRIBUTIONS 5,359,366. RETIREE PLAN - PRESCRIPTION REBATES 939,218. RETIREE PLAN - MEDICARE PT. D RETIREE DRUG SUBSIDIES 476,785. RETIREE PLAN - COMMISSION CREDITS 53,138. PART XII, LINE 4B - OTHER ADJUSTMENTS: RETIREE PLAN - MEDICAL BENEFITS 2,130,366. RETIREE PLAN - PRESCRIPTION BENEFITS 4,986,466. RETIREE PLAN - MEDICAL PREMIUMS 2,048,909. RETIREE PLAN - HMO PREMIUMS 160,703. RETIREE PLAN - PPO FEES & PROVIDER FEES 246,032. RETIREE PLAN - ADMINISTRATIVE EXPENSES 275,709. RETIREE PLAN - FEES MANDATED BY ACA 3,998. 0 0 0 KIM CORDOVA TRUSTEE 0 178767 0 0 0 10085 0 2184 0 9906 0 200942 0 0 KEVIN SCHNEIDER TRUSTEE 0 156997 0 0 0 10085 0 2184 0 9455 0 178721 0 0 NATHANIEL BERNSTEIN TRUSTEE 0 150290 0 0 0 10085 0 2184 0 9455 0 172014 0 0 MARTIN GARCIA TRUSTEE - NEW 0 150987 0 0 0 0 0 2184 0 9455 0 162626 0 0 FORM 990, PART VI, SECTION A, LINE 3 THE BOARD OF TRUSTEES HAS DELEGATED THE RECORD KEEPING AND DAY TO DAY ADMINISRATION OF THE PLAN TO ZENITH AMERICAN SOLUTIONS. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 IS PROVIDED TO THE ENTIRE BOARD OF TRUSTEES AND PLAN ADMINISTRATOR PRIOR TO FILING. AFTER THE BOARDS' REVIEW, THE FORM IS APPROVED AND FILED. FORM 990, PART VI, SECTION B, LINE 12C THE BOARD OF TRUSTEES IS REQUIRED TO DISCLOSE ANY NONADHERENCE TO THE ADOPTED POLICY. FORM 990, PART VI, SECTION C, LINE 19 THE GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE UPON REQUEST AT THE PLAN OFFICE. ROCKY MTN UFCW UNIONS AND EMPRS RETAIL AND MEAT PENSION PLAN 5511 W 56TH AVE SUITE 250 ARVADA CO 80002 846045986 PROVIDE PENSION BENEFITS TO ELIGIBLE PARTICIPANTS AND BENEFICIARIES CO 401(A) N/A 0 UNITED FOOD AND COMMERICAL WORKERS INTERNATIONAL UNION 7R LOCAL CONTRIBUTING EMPLOYER 0 ALBERTSONS SAFEWAY CONTRIBUTING EMPLOYER 0 ALMAGNO FREELANCE CONTRIBUTING EMPLOYER 0 DARLING INTERNATIONAL CONTRIBUTING EMPLOYER 0 DEBONAIRE HAIR CONTRIBUTING EMPLOYER 0 DENVER PROCESSING (KS - MEAT PLANT) CONTRIBUTING EMPLOYER 0 IMAGES - A LIZZI CONTRIBUTING EMPLOYER 0 KING SOOPERSCITY MARKETSMITH FOODS CONTRIBUTING EMPLOYER 0 THE PERFECT TOUCH CONTRIBUTING EMPLOYER 0 ZENITH AMERICAN SOLUTIONS CONTRIBUTING EMPLOYER 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 ROCKY MOUNTAIN UFCW UNIONS & EMPLOYERS RETAIL AND MEAT PENSION PLAN S 4136160 COST