2015-01-31T10:00:31-06:00 2014-04-30 320043599 LEGACY PROFESSIONALS LLP 311 S WACKER DRIVE STE 4000 CHICAGO IL 60606 990 2013-05-01 846044454 ROCKY MOUNTAIN UFCW UNIONS & EMPLOYERS HEALTH BENEFIT FUND ROCK 3034301118 5511 W 56TH AVE NO 250 ARVADA CO 800022815 STEVE DICROCE TRUSTEE 3034301118 2015-01-31 1 TIMOTHY CIBULKA P00841100 3123680500 2013 2016-02-25 16:41:14Z STEVE DICROCE 5511 W 56TH AVE NO 250 ARVADA CO 800022815 123191762 0 X N/A X 1965 CO PROVIDE HEALTH BENEFITS 6 3 0 0 0 0 0 0 122193821 122155144 29911 25277 0 8396 122223732 122188817 0 0 113897145 101721271 0 0 0 0 0 7754594 8041212 121651739 109762483 571993 12426334 30871530 43553270 359830 621006 30511700 42932264 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 228023 12901 KEVIN SCHNEIDER TRUSTEE 1.00 45.00 X 0 147048 12901 NATHAN BERNSTEIN TRUSTEE 1.00 45.00 X 0 144003 12901 0 519074 38703 0 0 1 0 CIGNA 900 COTTAGE GROVE ROAD HARTFORD CT 06152 PPO ACCESS AND ADMIN FEES 5254693 ZENITH AMERICAN SOLUTIONS 5511 W 56TH AVE STE 250 ARVADA CO 80002 THIRD PARTY ADMINISTRATOR 1419532 DELTA DENTAL 4582 S ULSTER STREET STE 800 DENVER CO 80237 BENEFIT ADMIN FEES 343496 THE SEGAL COMPANY 101 N WACKER DRIVE STE 500 CHICAGO IL 60606 ACTUARIAL SERVICES 343319 REINHART BOERNER VAN DEURAN SC 1000 WATER STREET STE 1700 MILWAUKEE WI 53202 LEGAL SERVICES 267911 9 EMPLOYER CONTRIBUTIONS 900099 106487173 106487173 PARTICIPANT CONTRIBUTIONS 900099 13835721 13835721 PRESCRIPTION REBATES 900099 957563 957563 MEDICARE PT. D RETIREE DRUG SUBSI 900099 703687 703687 BENEFITS CLAIMS REFUND 900099 171000 171000 122155144 28222 28222 1000000 1002945 -2945 -2945 -2945 MISCELLANEOUS INCOME 900099 8396 8396 8396 122188817 122155144 0 33673 101721271 1383840 579016 70788 14828 5655793 264258 24652 47227 MEMBERSHIP DUES 810 109762483 11545509 8029119 5512743 21912122 10004872 10335506 41848 0 3766558 3276523 30871530 43553270 235470 507331 124360 113675 359830 621006 X 0 0 0 0 30511700 42932264 30511700 42932264 30871530 43553270 12426334 -5770 0 X X 0 1 X 1 0 0 X 111883215 0 111883215 10305602 10305602 122188817 99702533 0 99702533 10059950 10059950 109762483 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 2,906,189. RETIREE PLAN INVESTMENT INTEREST 27,479. RETIREE PLAN RETIREE CONTRIBUTIONS 6,334,183. RETIREE PLAN PRESCRIPTION REBATES 337,009. RETIREE PLAN MEDICARE PT. D RETIREE DRUG SUBSIDIES 703,687. RETIREE PLAN REALIZED LOSS ON INVESTMENT SOLD -2,945. PART XII, LINE 4B - OTHER ADJUSTMENTS: RETIREE PLAN MEDICAL BENEFITS 3,480,603. RETIREE PLAN PRESCRIPTION BENEFITS 3,566,976. RETIREE PLAN MEDICAL PREMIUMS 2,447,583. RETIREE PLAN PPO FEES & PROVIDER FEES 222,105. ADMINISTRATIVE EXPENSES 336,078. RETIREE PLAN INVESTMENT FEES 6,605. 0 0 0 KIM CORDOVA TRUSTEE 0 228023 0 0 0 0 0 2995 0 9906 0 240924 0 0 KEVIN SCHNEIDER TRUSTEE 0 147048 0 0 0 0 0 2995 0 9906 0 159949 0 0 NATHAN BERNSTEIN TRUSTEE 0 144003 0 0 0 0 0 2995 0 9906 0 156904 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. 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 / LABOR UNION 0 ALBERTSONS CONTRIBUTING EMPLOYER 0 ALMAGNO FREELANCE CONTRIBUTING EMPLOYER 0 DARLING INTERNATIONAL CONTRIBUTING EMPLOYER 0 D'CARLO HAIR SALON CONTRIBUTING EMPLOYER 0 DEBONAIRE HAIR CONTRIBUTING EMPLOYER 0 GARRISON STREET STYLISTS CONTRIBUTING EMPLOYER 0 GARY & CORI LEETE CONTRIBUTING EMPLOYER 0 GARY MONTANA SALON INC 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 SAFEWAY 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 3428630 COST DENVER AREA MEAT CUTTERS & EMPLOYERS PENSION PLAN S 1357675 COST