2017-11-10T10:20:53-06:00 2016-12-31 320043599 LEGACY PROFESSIONALS LLP 222 INDIANAPOLIS BOULEVARD SUITE 103 SCHERERVILLE IN 46375 990 2016-01-01 367485085 MIDDLETOWN WORKS HOURLY & SALARIED UNION RETIREES HEALTH CARE FUND MIDD 8778295500 1201 CRAWFORD STREET MIDDLETOWN OH 45044 JAY YOUNGDAHL CO-CHAIR 8778295500 2017-11-10 1 RENEE SPECK P00201492 3123680500 12.197.118.215 2017-11-10 10:20:45 CS P D56625F7C0621E1EB8BA8C5A7372C18F0F4BC985 C3168D624729577079CA47B99B0ED2C5793BD89E 2016 2017-02-10 21:41:12Z BRIAN DALEY 1201 CRAWFORD STREET MIDDLETOWN OH 45044 741287861 0 X N/A X 2008 OH TO PROVIDE HEALTH BENEFITS 5 0 0 0 0 0 0 0 12879676 12947247 5113689 32619157 0 400000 17993365 45966404 0 0 46779502 48709997 95500 92500 0 0 0 2835089 3286419 49710091 52088916 -31716726 -6122512 635943460 641611730 379674 277679 635563786 641334051 TO PROVIDE HEALTH BENEFITS 0 0 TO PROVIDE MEDICAL, PRESCRIPTION DRUG, DENTAL, VISION AND/OR LIFE INSURANCE BENEFITS FOR ELIGIBLE RETIREES 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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 X 12 0 1 0 0 1 DA HU IS MY NO PO SW SZ 0 0 0 0 0 0 X 5 0 0 1 0 0 0 0 0 1 1 0 0 1 0 0 1 0 0 0 X ZENITH AMERICAN SOLUTIONS 8778295500 1201 CRAWFORD STREET MIDDLETOWN OH 45044 JAY YOUNGDAHL CHAIR 8.00 X 24000 0 0 BRIAN DALEY CO-CHAIR 8.00 X 8875 0 0 ROGER MCCLOW TRUSTEE 8.00 X 22500 0 0 ROGER MINOR TRUSTEE 8.00 X 9875 0 0 MICHAEL BAILEY TRUSTEE 8.00 X 7125 0 0 72375 0 0 0 0 0 0 ZENITH AMERICAN SOLUTIONS INC 3333 N MAYFAIR RD STE 201 WAUWATOSA WI 53222 THIRD PARTY ADMINISTRATOR & CLAIMS PROCE 814291 EXPRESS SCRIPTS 100 PARSONS POND DRIVE FRANKLIN LAKES NJ 07417 PHARMACY BENEFIT MANAGER 532937 UNITED HEALTHCARE SERVICES INC 185 ASYLUM STREET HARTFORD CT 06103 MEDICAL NETWORK ACCESS 393781 PIMCO 1633 BROADWAY 46TH FLOOR NEW YORK NY 10019 INVESTMENT MANAGER 187649 WELLS FARGO 90 SOUTH 7TH STREET N9305-164 MINNEAPOLIS MN 55402 INVESTMENT MANAGER 149768 10 EMPLOYER GROUP WAIVER PLAN REBATE 900099 5343327 5343327 SELF PAY CONTRIBUTIONS 900099 3956606 3956606 PRESCRIPTION DRUG REBATES 900099 3647314 3647314 12947247 13895220 13895220 714045394 695321457 18723937 18723937 18723937 SETTLEMENT INCOME 900099 400000 400000 400000 45966404 12947247 0 33019157 48709997 92500 324047 205777 23320 928864 1459170 194363 33334 63866 FEES MANDATED BY ACA 46368 RETIREE ASSISTANCE COMM 7245 CLAIMS ASSESSMENT TAX 65 52088916 49582 91938 5705625 16879209 5043447 6926119 25247 21282 274049347 617693182 351070212 635943460 641611730 305574 198054 74100 79625 379674 277679 X 0 0 0 0 635563786 641334051 635563786 641334051 635943460 641611730 -6122512 11892777 0 X 0 1 X 1 0 0 X 56930317 11892777 11892777 45037540 928864 928864 45966404 51160052 0 51160052 928864 928864 52088916 PART X, LINE 2: THE PLAN FILES FORM 990, RETURN OF ORGANIZATION EXEMPT FROM INCOME TAX, AND FORM 5500, ANNUAL RETURN/REPORT OF EMPLOYEE BENEFIT PLAN. THE PLAN'S RETURNS ARE SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE UNTIL THE APPLICABLE STATUE OF LIMITATION EXPIRES. FORM 990, PART VI, SECTION A, LINE 3 ALTHOUGH THE TRUSTEES MAINTAIN ULTIMATE CONTROL AND RESPONSIBILITY FOR THE PLAN, THEY HAVE DELEGATED THE DAY-TO-DAY ADMINISTRATIVE DUTIES TO ZENITH AMERICAN SOLUTIONS, INC. AS THE THIRD PARTY ADMINISTRATOR OF THE PLAN. FORM 990, PART VI, SECTION B, LINE 11B A COPY OF THE FORM 990 WAS PROVIDED TO THE ENTIRE BOARD OF TRUSTEES FOR THEIR REVIEW. FORM 990 IS SIGNED AND FILED ONLY AFTER ALL QUESTIONS ARE ANSWERED AND ANY REVIEW CHANGES ARE MADE. FORM 990, PART VI, SECTION B, LINE 15 ALTHOUGH THE PLAN HAS NOT USED THE METHODS LISTED IN PART VI, SECTION B, NUMBER 15 TO DETERMINE COMPENSATION, THE PLAN HAS ADOPTED A FORMAL COMPENSATION POLICY. FORM 990, PART VI, SECTION C, LINE 19 THE PLAN DISTRIBUTES THE SUMMARY PLAN DESCRIPTION TO PLAN PARTICIPANTS AND PLAN PARTICIPANTS MAY REQUEST A COPY OF FORM 5500 ANNUAL REPORT, INCLUDING A FINANCIAL STATEMENT, FROM THE PLAN. OTHER PLAN DOCUMENTS THAT ARE REQUIRED TO BE DISCLOSED UNDER FEDERAL LAW, INCLUDING THE EMPLOYEE RETIREMENT AND INCOME SECURITY ACT OF 1974, AS AMENDED, ARE AVAILABLE UPON REQUEST.