2017-02-13T17:10:43-06:00 2016-04-30 320043599 LEGACY PROFESSIONALS LLP 311 S WACKER DRIVE STE 4000 CHICAGO IL 60606 990 2015-05-01 846044454 ROCKY MOUNTAIN UFCW UNIONS & EMPLOYERS HEALTH BENEFIT FUND ROCK 3034301118 5511 W 56TH AVE NO 250 ARVADA CO 800022815 STEVE DICROCE TRUSTEE 3034301118 2017-02-13 1 TIMOTHY CIBULKA P00841100 3123680500 2015 2021-01-29 14:40:06Z STEVE DICROCE 5511 W 56TH AVE NO 250 ARVADA CO 800022815 120103859 0 X N/A X 1965 CO PROVIDE HEALTH BENEFITS 6 3 0 0 0 0 0 0 118605774 119216193 18238 20078 7669 117263 118631681 119353534 0 0 107687828 107993683 0 0 0 0 0 9871387 8887423 117559215 116881106 1072466 2472428 44503097 46848945 508820 391010 43994277 46457935 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 X 6 3 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 BRYAN SMITH TRUSTEE 1.00 X 0 0 0 DANNY MA TRUSTEE 1.00 X 0 0 0 KIM CORDOVA TRUSTEE 1.00 45.00 X 0 176485 12901 KEVIN SCHNEIDER TRUSTEE 1.00 45.00 X 0 160928 12901 NATHANIEL BERNSTEIN TRUSTEE 1.00 45.00 X 0 151755 12901 0 489168 38703 0 0 1 0 CIGNA 900 COTTAGE GROVE ROAD HARTFORD CT 06152 PPO ACCESS AND ADMIN FEES 4851623 ZENITH AMERICAN SOLUTIONS 5511 W 56TH AVE STE 250 ARVADA CO 80002 THIRD PARTY ADMINISTRATOR 2123175 DELTA DENTAL 4582 S ULSTER STREET STE 800 DENVER CO 80237 BENEFIT ADMIN FEES 317481 THE SEGAL COMPANY 101 N WACKER DRIVE STE 500 CHICAGO IL 60606 ACTUARIAL SERVICES 277502 REINHART BOERNER VAN DEURAN SC 1000 N WATER ST STE 1700 MILWAUKEE WI 53202 LEGAL SERVICES 235666 6 EMPLOYER CONTRIBUTIONS 900099 102991970 102991970 PARTICIPANT CONTRIBUTIONS 900099 12788701 12788701 PRESCRIPTION REBATES 900099 2483472 2483472 MEDICARE PT. D RETIREE DRUG SUBSI 900099 565679 565679 BENEFITS CLAIMS REFUND 900099 386371 386371 119216193 20403 20403 750000 750325 -325 -325 -325 COMMISSION CREDITS 900099 100292 100292 MISCELLANEOUS INCOME 900099 16971 16971 117263 119353534 119216193 0 137341 107993683 1891788 284310 79860 74 5705911 259279 15647 47360 FEES MANDATED BY ACA 603194 116881106 6132235 3744585 27550437 31593021 9518532 11010389 41848 0 1260045 500950 44503097 46848945 401887 288860 105200 102150 1733 0 508820 391010 X 0 0 0 0 43994277 46457935 43994277 46457935 44503097 46848945 X 2472428 -8770 0 X X 0 1 X 1 0 0 X 109351027 0 109351027 10002507 10002507 119353534 106595070 0 106595070 10286036 10286036 116881106 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 STATUTE OF LIMITATION EXPIRES. PART XI, LINE 4B - OTHER ADJUSTMENTS: RETIREE PLAN - EMPLOYER CONTRIBUTIONS 2,748,155. RETIREE PLAN - INVESTMENT INTEREST 14,407. RETIREE PLAN - RETIREE CONTRIBUTIONS 5,567,223. RETIREE PLAN - PRESCRIPTION REBATES 620,705. RETIREE PLAN - MEDICARE PT. D RETIREE DRUG SUBSIDIES 565,679. RETIREE PLAN - REALIZED LOSS ON INVESTMENT SOLD -325. RETIREE PLAN - BENEFIT CLAIMS REFUND 386,371. RETIREE PLAN - COMMISSION CREDITS 100,292. PART XII, LINE 4B - OTHER ADJUSTMENTS: RETIREE PLAN - MEDICAL BENEFITS 3,476,873. RETIREE PLAN - PRESCRIPTION BENEFITS 4,338,661. RETIREE PLAN - MEDICAL PREMIUMS 1,762,083. RETIREE PLAN - HMO PREMIUMS 98,045. RETIREE PLAN - PPO FEES & PROVIDER FEES 275,416. RETIREE PLAN - ADMINISTRATIVE EXPENSES 315,073. RETIREE PLAN - FEES MANDATED BY ACA 19,811. RETIREE PLAN - INVESTMENT FEES 74. 0 0 0 KIM CORDOVA TRUSTEE 0 175530 0 0 0 955 0 2995 0 9906 0 189386 0 0 KEVIN SCHNEIDER TRUSTEE 0 160120 0 0 0 808 0 2995 0 9906 0 173829 0 0 NATHANIEL BERNSTEIN TRUSTEE 0 151755 0 0 0 0 0 2995 0 9906 0 164656 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 11 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 ARE REQUIRED TO DISCLOSE ANY NONADHERANCE 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. FORM 990, PART XI, LINE 5: THE $8,770 NET UNREALIZED LOSSES PERTAINS TO THE ROCKY MOUNTAIN UFCW UNIONS AND EMPLOYERS HEALTH BENEFIT FUND - RETIREE. SEE NOTE IN SCHEDULE O, PART XII, LINE 2B FOR FURTHER EXPLAINATION. ROCKY MOUNTAIN UFCW UNIONS AND EMPLOYERS 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 DENVER AREA MEAT CUTTERS AND EMPLOYERS PENSION PLAN 5511 W 56TH AVE SUITE 250 ARVADA CO 80002 846097461 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 GARY & CORI LEETE CONTRIBUTING EMPLOYER 0 IMAGES - A LIZZI CONTRIBUTING EMPLOYER 0 KING SOOPERS CONTRIBUTING EMPLOYER 0 MOSHO'S BARBER SERVICE 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 PENSION PLAN S 3065268 COST DENVER AREA MEAT CUTTERS & EMPLOYERS PENSION PLAN S 1186120 COST