2017-06-07T16:27:29-05:00 2016-07-31 522385296 LINDQUIST LLP 5000 EXECUTIVE PARKWAY SUITE 400 SAN RAMON CA 945834210 990 2015-08-01 946072965 BAY AREA DELIVERY DRIVERS SECURITY FUND BAYA 9258337300 4160 DUBLIN BLVD NO 400 DUBLIN CA 94568 JACK BOOKTER TRUSTEE 4154670450 2017-06-07 1 JASMINE S BAKER P01452246 9252779100 2015 2021-01-29 14:40:06Z JACK BOOKTER 4160 DUBLIN BLVD NO 400 DUBLIN CA 94568 49922366 0 X N/A X 1950 CA TO PROVIDE HEALTH AND WELFARE BENEFITS 6 5 0 0 0 0 0 0 42092862 40921480 18855 343702 0 0 42111717 41265182 0 0 39571174 36823208 0 0 0 0 0 1365428 1514433 40936602 38337641 1175115 2927541 19124937 22016276 6754544 6635711 12370393 15380565 PROVIDE HEALTH AND WELFARE BENEFITS FOR ELIGIBLE PARTICIPANTS AND THEIR DEPENDENTS. 0 0 PROVIDED HEALTH AND WELFARE BENEFITS FOR ELIGIBLE PARTICIPANTS AND THEIR DEPENDENTS. 0 0 0 0 0 0 0 0 0 0 1 0 0 1 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 1 998 0 1 0 0 0 0 0 0 0 X 6 5 0 1 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 0 0 0 X HEALTH SERVICES & BENEFIT ADMIN 9258337300 4160 DUBLIN BLVD SUITE 400 DUBLIN CA 94551 X JACK BOOKTER TRUSTEE 1.00 X 0 0 0 DENNIS HART TRUSTEE 1.00 X 0 0 0 FRANK CADEMARTI TRUSTEE 1.00 X 0 0 0 DEBBIE FIELD PAST TRUSTEE 1.00 X 0 0 0 RICHARD RODRIGUEZ TRUSTEE 1.00 X 0 0 0 STEVEN BOULTON TRUSTEE 1.00 X 0 0 0 LESLIE REA TRUSTEE 1.00 X 0 0 0 0 0 0 0 0 0 0 HEALTH SERVICES & BENEFIT ADMINISTRATORS 4160 DUBLIN BLVD STE 400 DUBLIN CA 94568 PLAN ADMINISTRATOR 785289 BLUE CROSS OF CALIFORNIA 700 BROADWAY DENVER CO 80273 COST CONTAINMENT 225100 THE SEGAL COMPANY 100 MONTGOMERY ST 500 SAN FRANCISCO CA 94104 CONSULTANT 141462 3 EMPLOYER CONTRIBUTIONS 900099 39348284 39348284 REBATES AND REFUNDS 900099 738216 738216 STOP LOSS REFUNDS 900099 285424 285424 PARTICIPANT CONTRIBUTIONS 900099 248939 248939 MEDICARE DRUG SUBSIDY 900099 209148 209148 91469 91469 40921480 270357 270357 8730529 8657184 73345 73345 73345 41265182 40921480 0 343702 36823208 764386 95114 38040 19328 401731 59245 18748 19748 TRANSITIONAL REINSURANC 90332 PCORI FEE 6255 MISCELLANEOUS EXPENSE 1506 38337641 2087289 2643732 9060501 7508042 5799626 4210614 12742 5058 1270512 6662419 894267 986411 19124937 22016276 254544 138711 6500000 6497000 6754544 6635711 X 0 0 0 0 12370393 15380565 12370393 15380565 19124937 22016276 2927541 82631 0 X X 0 1 X 1 0 0 MUTUAL FUNDS 6662419 F 6662419 CLAIMS PAYABLE AND IBNR 2826000 PREMIUMS PAYABLE 1067000 ACCUMULATED ELIGIBILITY CREDITS 2604000 6497000 X 41328485 82631 82631 41245854 19328 19328 41265182 38321313 0 38321313 19328 -3000 16328 38337641 PART X, LINE 2: THE PLAN'S ADMINISTRATOR HAS ANALYZED THE TAX POSITIONS TAKEN BY THE PLAN AND HAS CONCLUDED THAT, AS OF JULY 31, 2016, THERE ARE NO UNCERTAIN POSITIONS TAKEN OR EXPECTED TO BE TAKEN THAT WOULD REQUIRE RECOGNITION OF A LIABILITY OR DISCLOSURE IN THE FINANCIAL STATEMENTS. THE PLAN IS SUBJECT TO ROUTINE AUDITS BY THE TAXING JURISDICTIONS; HOWEVER, THERE ARE CURRENTLY NO AUDITS FOR ANY TAX PERIODS IN PROGRESS. THE PLAN BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR THE FISCAL YEARS PRIOR TO 2013. PART XII, LINE 4B - OTHER ADJUSTMENTS: CHANGE IN BENEFIT OBLIGATION FORM 990, PART VI, SECTION A, LINE 3 THE PLAN HAS CONTRACTED WITH HEALTH SERVICES & BENEFIT ADMINISTRATORS INC. TO PROVIDE ADMINISTRATIVE SERVICES FOR THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 8B THE ORGANIZATION HAS NO COMMITTEES TO ACT ON BEHALF OF THE BOARD OF TRUSTEES. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 WAS PROVIDED TO THE BOARD OF TRUSTEES FOR REVIEW BEFORE IT WAS FILED. REVIEW OF THE FORM 990 WAS CONDUCTED BY THE BOARD PRIOR TO FILING WITH THE IRS. FORM 990, PART VI, SECTION B, LINE 12C THE MEMBERS OF THE BOARD OF TRUSTEES DISCLOSE ANY CONFLICTS WHEN THEY ARE PROVIDED THE FORM 990, BEFORE IT IS FILED. THE POLICY IS CONSISTENTLY MONITORED AND ENFORCED. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT-OF-INTEREST POLICY OR FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. UPON REQUEST, THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT-OF-INTEREST POLICY AND FINANCIAL INFORMATION AVAILABLE TO THE PARTICIPANTS AND CONTRIBUTING EMPLOYERS. FORM 990, PART XII, LINE 2C: THE ORGANIZATION HAS A BOARD OF TRUSTEES THAT ASSUMES THE RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED. RETAIL DELIVERY DRIVERS SALESMEN & HELPERS UNION LOCAL 278 940801849 PLAN SPONSOR CA 501 (C) (5) N/A N/A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SCHEDULE R, IDENTIFICATION OF RELATED ORGANIZATIONS: THE FILING ORGANIZATION IS A TAFT-HARTLEY MULTIEMPLOYER TRUST THAT PROVIDES HEALTH AND WELFARE BENEFITS TO ELIGIBLE EMPLOYEES AND THEIR DEPENDENTS. AS OF JULY 31, 2016, THERE ARE APPROXIMATELY 13 EMPLOYERS THAT CONTRIBUTE TO THE TRUST. THE ADMINISTRATIVE OFFICE MAINTAINS A DATABASE OF THESE CONTRIBUTING EMPLOYERS INCLUDING NAMES, ADDRESES AND OTHER CONTACT INFORMATION. THE FEDERAL TAX CLASSIFICATION (DISREGARDED ENTITY, TAX-EXEMPT ORGANIZATION, PARTNERSHIP, TAXABLE CORPORATION OR TRUST) FOR EACH CONTRIBUTING EMPLOYER IS NOT ON FILE WITH THE ADMINISTRATIVE OFFICE AND IT COULD NOT BE REASONABLY OBTAINED. AS A RESULT, THE NAMES OF THE CONTRIBUTING EMPLOYERS ARE LISTED ON PART VII BELOW, AND NOT ON PARTS II THROUGH IV BY FEDERAL TAX CLASSIFICATION. DS WATERS OF AMERICA HILLS PET NUTRITION UNITED PARCEL SERVICE ELWELL TRUCKING, INC. HOME MAID RAVIOLI KING AMERICAN AMBULANCE RUAN TRANSPORT CORP. INSHALAH IMPORTS INC. TWO G'S CATERING, INC. FOOD SERVICE PARTNERS WILCOX FROZEN FOODS, INC. HS&BA TEAMSTERS LOCAL 2785