2018-04-09T16:14:45-05:00 2017-11-30 320043599 LEGACY PROFESSIONALS LLP 311 S WACKER DRIVE STE 4000 CHICAGO IL 60606 990 2016-12-01 351065816 UNITED FOOD & COMM WORKERS CALUMET REGION INSURANCE FUND UNIT 8473847000 9801 WEST HIGGINS ROAD NO 500 ROSEMONT IL 60018 ROBERT NIKSA FUND ADMINISTRATOR 8473847000 2018-04-09 1 BRUCE A PAVLIK P00748405 3123680500 12.197.118.215 2018-04-09 16:13:42 CD P BA45EDD38AF72032A546CB0196E8643A6430FCCD C3168D624729577079CA47B99B0ED2C5793BD89E 2016 2021-01-29 14:40:06Z ROBERT NIKSA 9801 WEST HIGGINS ROAD NO 500 ROSEMONT IL 60018 10438037 0 X N/A X 1960 IL PROVIDE HEALTH BENEFITS 4 4 0 0 0 0 0 0 8006516 6813661 144069 158817 17654 91 8168239 6972569 0 0 8874278 8173353 0 0 0 0 0 522483 439253 9396761 8612606 -1228522 -1640037 6601662 5303173 40556 26048 6561106 5277125 PROVIDE HEALTH BENEFITS 0 0 TO PROVIDE HEALTH AND WELFARE, DEATH, AND LOSS OF TIME BENEFITS TO ELIGIBLE PARTICIPANTS AND/OR 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 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 42 0 1 0 0 0 0 0 0 0 0 0 X 4 4 0 1 0 0 0 0 0 1 0 0 0 1 1 0 0 1 0 0 0 0 X ROBERT NIKSA 8479397220 9801 WEST HIGGINS ROAD ROSEMONT IL 60018 X STEVEN POWELL TRUSTEE 1.00 X 0 0 0 SAMUEL VAN TIL TRUSTEE 1.00 X 0 0 0 LISA CATANZARO TRUSTEE 1.00 X 0 0 0 JEFFREY STRACK TRUSTEE 1.00 X 0 0 0 HARRY GROW TRUSTEE - ALTERNATE 1.00 X 0 0 0 DEREK KINNEY TRUSTEE - ALTERNATE 1.00 X 0 0 0 RICHARD BUGAJSKI TRUSTEE - ALTERNATE 1.00 X 0 0 0 0 0 0 0 0 0 0 BLUE CROSS BLUE SHIELD 300 EAST RANDOLPH ST CHICAGO IL 60601 PPO PROVIDER 452011 1 EMPLOYER CONTRIBUTIONS 900099 6713196 6713196 STOP LOSS REFUNDS 900099 67477 67477 PARTICIPANT CONTRIBUTIONS 900099 32988 32988 6813661 136695 136695 3487590 3465468 22122 22122 22122 MISCELLANEOUS 900099 91 91 91 6972569 6813661 0 158908 8173353 245258 14403 32984 35160 61407 18007 1056 12567 WEB CLAIMS SERVICE FEE 14836 FEES MANDATED BY ACA 3575 8612606 54934 74716 74310 199614 88871 39882 6041 15098 6349247 4933501 28259 40362 6601662 5303173 40556 26048 40556 26048 X 0 0 0 0 6561106 5277125 6561106 5277125 6601662 5303173 -1640037 356056 0 X 0 1 X 1 0 0 X 7293465 356056 356056 6937409 35160 35160 6972569 8577446 0 8577446 35160 35160 8612606 PART X, LINE 2: ACCOUNTING PRINCIPLES GENERALLY ACCEPTED IN THE UNITED STATES OF AMERICA REQUIRE THE PLAN TO EVALUATE ITS 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. FORM 990, PART VI, SECTION A, LINE 3 THE PLAN IS ADMINISTERED AND MANAGED BY THE UNITED FOOD AND COMMERCIAL WORKERS UNION AND EMPLOYERS (UFCW) MIDWEST HEALTH BENEFITS FUND. THE PLAN REIMBURSES THE UFCW MIDWEST HEALTH BENEFITS FUND FOR CERTAIN COMMON ADMINISTRATIVE EXPENSES BASED ON A PER MEMBER FEE AGREEMENT. FORM 990, PART VI, SECTION A, LINE 8B THE PLAN HAS NO COMMITTEES WITH THE AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY (TRUSTEES). FORM 990, PART VI, SECTION B, LINE 11B THE COMPLETED FORM 990 IS PROVIDED TO THE ENTIRE BOARD OF TRUSTEES. ONCE THE FORM IS REVIEWED AND APPROVED, IT IS SIGNED AND FILED. FORM 990, PART VI, SECTION C, LINE 19 GOVERNING DOCUMENTS,CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST AT THE FUND OFFICE. STRACK-ULTRA LLC CONTRIBUTING EMPLOYER 0 LAKE COUNTY NURSING INC CONTRIBUTING EMPLOYER 0 HAPPY FOODS INC CONTRIBUTING EMPLOYER 0 INDIANA GROCERY GROUP CONTRIBUTING EMPLOYER 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1