2017-11-15T11:23:20-06:00 2016-12-31 391531945 FREYBERG HINKLE ASHLAND POWERS & STOWELL 15420 W CAPITOL DR BROOKFIELD WI 530052621 990 2016-01-01 310656412 UFCW UNIONS & EMPLOYERS HEALTH & WELFARE PLAN OF CENTRAL OHIO UFCW 6142377618 4150 EAST MAIN STREET COLUMBUS OH 43213 RANDY QUICKEL CHAIRMAN 6142377618 2017-11-03 1 THOMAS M POWERS CPA P00241729 2627846210 70.61.53.194 2017-11-03 08:37:52 CD P 2A3F482710C69FCCEFE18B634FA3E25425E25BFA 3972137AB098234AFA465114004C73B0D1EF18AE 2016 2017-02-10 21:41:12Z RANDY QUICKEL 4150 EAST MAIN STREET COLUMBUS OH 43213 73369477 0 X WWW.UFCWCENTRALOHIOHW.COM X 1956 OH PROVIDE INSURANCE BENEFITS FOR MEMBERS 6 6 12 0 0 0 0 0 44311592 62379291 521248 326355 0 0 44832840 62705646 0 0 56173543 60654460 933903 897687 0 0 0 3189315 3121917 60296761 64674064 -15463921 -1968418 16138116 15386128 2578662 3739869 13559454 11646259 TO PROVIDE FOR A UNIFORM HEALTH AND WELFARE PROGRAM FOR EMPLOYEES EMPLOYED UNDER CERTAIN COLLECTIVE BARGAINING AGREEMENTS. 0 0 62736005 BENEFITS PAID TO OR FOR MEMBERS CONSIST OF ACCIDENT, HEALTH, DENTAL, LOSS OF TIME, VISION CARE, PRESCRIPTION DRUG AND LIFE. ALSO INCLUDED ARE THE RELATED ADMINISTRATION FEES CHARGED BY THE BENEFIT PROVIDERS AND COST CONTROLS. 62736005 0 0 0 0 0 0 0 0 0 1 0 0 0 1 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 88 0 1 12 1 0 0 0 0 0 0 X 6 6 0 0 0 0 0 0 0 1 1 0 0 1 1 0 1 1 1 1 0 0 X LLOYD BLAKE 6142377618 4150 E MAIN ST COLUMBUS OH 43213 RANDY QUICKEL CHAIRMAN 2.00 45.00 X X 0 174400 27233 STEVE LOEFFLER SECRETARY 2.00 X X 0 0 0 PAUL SMITHBERGER TRUSTEE 2.00 45.00 X 0 138520 21513 MARK FLUHARTY TRUSTEE 2.00 45.00 X 0 148528 26661 KATHY WAGENKNECHT TRUSTEE 2.00 X 0 0 0 OLENA MALEKCYJ TRUSTEE 2.00 X 0 0 0 ROB FRANCIN TRUSTEE 2.00 X 0 0 0 LLOYD BLAKE ADMINISTRATIVE MANAGER 40.00 X 101469 0 21538 101469 461448 96945 1 0 1 0 HEALTHSMART CARE MGMT SOLUTIONS LP 6303 COMMMERCE DR SUITE 180 IRVING TX 75063 MEDICAL CASE MANAGEMENT 265104 REINHART BOERNER VAN DEUREN SC PO BOX 2965 MILWAUKEE WI 532012965 ATTORNEY 215620 BENESYS 700 TOWER DRIVE SUITE 300 TROY MI 48098 IT 131140 BUCK CONSULTANTS LLC 6000 FREEDOM SQUARE SUITE 100 INDEPENDENCE OH 44131 CONSULTANT 105338 4 EMPLOYER CONTRIBUTIONS 900099 61888137 61888137 SELF-PAYMENT CONTRIBUTI 900099 491154 491154 62379291 293002 293002 10697184 10663831 33353 33353 33353 62705646 62379291 0 326355 60654460 522273 26336 308792 40286 214495 35340 34282 136224 308667 171810 56559 22108 951 22238 ACCIDENT, HEALTH AND DE 1693785 MEDICAL REVIEW SERVICES 280034 VISION CARE FEES 56122 DISEASE MANAGEMENT PREM 51604 37698 64674064 1971063 2581222 64144 56554 144322 517866 137652 22792 335534 333391 2384 2143 13818551 12205551 16138116 15386128 1429215 2488148 3570 0 1145877 1251721 2578662 3739869 X 0 0 0 0 13559454 11646259 13559454 11646259 16138116 15386128 -1968418 55223 0 X X 0 1 X 1 0 335534 333391 2143 2143 CLAIMS PAYABLE 1175000 CASH OVERDRAFT 76721 1251721 X 62726587 55223 55223 62671364 34282 34282 62705646 64549782 0 64549782 34282 90000 124282 64674064 PART X, LINE 2: U.S. GENERALLY ACCEPTED ACCOUNTING PRINCIPLES REQUIRE PLAN MANAGEMENT TO EVALUATE TAX POSITIONS TAKEN BY THE PLAN AND RECOGNIZE A TAX LIABILITY (OR ASSET) IF THE PLAN HAS TAKEN AN UNCERTAIN POSITION THAT MORE LIKELY THAN NOT WOULD NOT BE SUSTAINED UPON EXAMINATION BY THE IRS. THE PLAN IS SUBJECT TO ROUTINE AUDITS BY TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX YEARS IN PROGRESS. PART XII, LINE 4B - OTHER ADJUSTMENTS: CURRENT YEAR INCREASE IN CLAIMS PAYABLE 90,000. 0 0 0 RANDY QUICKEL CHAIRMAN 0 166375 0 8025 0 0 0 0 0 27233 0 201633 0 0 PAUL SMITHBERGER TRUSTEE 0 133100 0 5420 0 0 0 0 0 21513 0 160033 0 0 MARK FLUHARTY TRUSTEE 0 141805 0 6723 0 0 0 0 0 26661 0 175189 0 0 FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 GOES THROUGH A PRELIMINARY REVIEW BY THE ADMINISTRATIVE MANAGER AND DIRECTOR OF FINANCE. ONCE THEY APPROVE THE FORM 990 IT IS PRESENTED TO A COMMITTEE OF TRUSTEES FOR APPROVAL PRIOR TO SIGNING AND FILING. FORM 990, PART VI, SECTION B, LINE 12C TRUSTEES ARE EXPECTED TO FULLY DISCLOSE ANY OWNERSHIP OR OTHER FINANCIAL RELATIONSHIPS THEY HAVE WITH OTHER PARTIES THAT DEAL WITH THE PLAN. FORM 990, PART VI, SECTION B, LINE 15A THE CHAIRMAN OF THE BOARD OF TRUSTEES EVALUATES THE ADMINISTRATIVE MANAGER AND DETERMINES COMPENSATION. FORM 990, PART VI, SECTION C, LINE 19 THE PLAN MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST. FORM 990, PART XII, LINE 2C: THE BOARD OF TRUSTEES IS RESPONSIBLE FOR THE SELECTION OF AN INDEPENDENT ACCOUNTANT TO PERFORM THE AUDIT OF THE PLAN'S FINANCIAL STATEMENT. FORM 990, SCHEDULE R, PARTS II-IV: IN ADDITION TO THE CONTRIBUTING EMPLOYERS REPORTED AS RELATED ORGANIZATIONS ON SCHEDULE R, PARTS II-IV, THE PLAN ALSO HAD 2 SOLE PROPRIETORS AS CONTRIBUTING EMPLOYERS DURING 2016. UNITED FOOD & COMMERCIAL WORKERS UNION LOCAL 1059 4150 E MAIN STREET COLUMBUS OH 43213 314392482 LABOR UNION OH 501(C)(5) N/A 0 BOARD OF TRUSTEES OF THE UFCW UNIONS AND EMPLOYERS H&W PLAN OF CENTRAL OHIO 4150 E MAIN STREET COLUMBUS OH 43213 310656412 PLAN SPONSOR AND PLAN ADMINISTRATOR OH 501(C)(9) N/A 0 CVSCAREMARK GREAT SCOT INC THE KROGER CO 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 UNITED FOOD & COMMERCIAL WORKERS UNION LOCAL 1059 K 67680 FAIR MARKET VALUE UNITED FOOD & COMMERCIAL WORKERS UNION LOCAL 1059 P 4193 ACTUAL EXPENSE REIMBURSEMENT