2014-06-13T13:24:07-05:00 2013-07-31 910614823 SCHOEDEL & SCHOEDEL CPAS PLLC 422 W RIVERSIDE AVE STE 1420 SPOKANE WA 992010395 990 2012-08-01 201842198 SEIU Healthcare NW Health Benefits Trust SEIU 4257717359 PO Box 6 Mukilteo WA 98275 Charissa Raynor 2538153728 2014-06-13 1 SCOTT OPPERUD CPA P00542597 5097472158 2014-05-30 2012 2015-11-30 17:44:51Z David Rolf PO Box 6 Mukilteo WA 98275 125875145 0 X www.myseiubenefits.org X 2004 WA The Trust was established as a result of collective bargaining between the Service Employees International Union, Local 775 (SEIU 775) and various employers or employer representatives signatory thereto to provide health, vision and dental benefits covering qualified employees reported under the collective bargaining agreements. 8 8 0 0 0 0 0 0 124546037 125854067 26497 21078 3717 0 124576251 125875145 0 0 116158847 129225279 0 0 0 0 0 2358374 2722813 118517221 131948092 6059030 -6072947 33951255 28254268 1556283 1932243 32394972 26322025 The Trust provides health and welfare benefits pursuant to collective bargaining agreements between various employers and the Trust. 0 0 The Trust was established as a result of collective bargaining between SEIU 775 and various employers or employer representatives signatory thereto to provide health, vision and dental benefits covering qualified employees reported under the collective bargaining agreements. 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 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 2 0 1 0 0 0 0 0 0 0 X 8 8 1 1 0 0 0 1 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X Benefit Solutions Inc 4257717359 12121 Harbour Reach Drive Ste 105 Mukilteo WA 98275 David Rolf 1.00 X X 0 0 0 Sterling Harders 1.00 X 0 0 0 Misha Werschkul 1.00 X 0 0 0 Seth Hemond 1.00 X 0 0 0 Eric Erickson 1.00 X 0 0 0 Dan Murphy 1.00 X 0 0 0 Diane Lutz 1.00 X 0 0 0 Flanna Perkins 1.00 X 0 0 0 Charissa Raynor 10.00 X 0 124109 0 0 124109 0 0 0 0 0 SEIU Healthcare NW Training Partnership 215 Columbia Street Seattle WA 98104 Plan administration 595073 Benefit Solutions Inc 12121 Harbour Reach Drive Suite 10 Mukilteo WA 98275 Contract administrator 587674 Delta Dental of Washington 9706 Fourth Avenue NE Seattle WA 981152157 Dental claims administrator 302975 SEIU Healthcare 775NW 33615 1st Way South Suite A Federal Way WA 98003 Member resource center 265576 Brown & Brown of WA Inc dba DiMartino 1501 Fourth Avenue Suite 2400 Seattle WA 98101 Benefits consulting 165000 6 Employer contributions 525100 121784016 121784016 Participant contributions 525100 4057746 4057746 Employer late charges 525100 12305 12305 125854067 21078 21078 125875145 125854067 0 21078 129225279 1817347 130475 25667 231778 21857 131017 317073 6723 649 10885 Dues 29342 131948092 20833373 13084490 13094098 15155764 12594 12230 11190 1784 33951255 28254268 251283 146743 1305000 1785500 1556283 1932243 X 0 0 0 0 32394972 26322025 32394972 26322025 33951255 28254268 -6072947 0 X 0 1 X 0 0 0 Dental claims payable 420000 Premiums due to insurers 1105500 Dental claims incurred but not reported 260000 1785500 125875145 0 125875145 0 125875145 131948092 0 131948092 0 131948092 Form 990, Part VI, Section A, line 2 SEIU Healthcare 775NW and the SEIU Healthcare NW Training Partnership are service providers to this trust as well as participating employers. David Rolf is the Chairman of this trust, the President of SEIU Healthcare 775NW, and the Chairman of the SEIU Healthcare NW Training Partnership. Misha Werschkul is a trustee of this trust and an employee of SEIU Healthcare 775NW. Seth Hedmond is a trustee of this trust, an employee of SEIU Healthcare 775NW, and a trustee of the SEIU Healthcare NW Training Partnership. Sterling Harders is a trustee of this trust, the Vice President of SEIU Healthcare 775NW, and a trustee of the SEIU Healthcare NW Training Partnership. Dan Murphy is a trustee of this trust, a trustee of SEIU Healthcare NW Training Partnership, and an employee of the State of Washington, an employer of record participating in this trust. Eric Erickson is a trustee of this trust and an employee of CDM Services, a participating employer of this trust. Diane Lutz is a trustee of this trust and an employee of the State of Washington, an employer of record participating in this trust. Flanna Perkins is a trustee of this trust, a trustee of SEIU Healthcare NW Training Partnership, and an employee of ResCare Homecare, a participating employer of this trust. Charissa Raynor is the Executive Director of this trust and the Executive Director of the SEIU Healthcare NW Training Partnership. Form 990, Part VI, Section A, line 3 The Trust has contracted with various organizations (Benefit Solutions, Inc., Delta Dental of Washington, SEIU Healthcare NW Training Partnership, and SEIU Healthcare 775NW) to provide administrative, bookkeping, claims processing, member communications, and record keeping services. Form 990, Part VI, Section A, line 7a There are four voting Labor Trustees and four voting Employer Trustees. Any vacancies of Employer Trustees are filled by appointment of the remaining Employer Trustees. The appointment of an Employer Trustee may be terminated, at any time, by the remaining Employer Trustees by such method as is satisfactory to them. Any vacancies of the Labor Trustees are filled by appointment of the president of SEIU Healthcare 775NW according to SEIU Healthcare 775NW's internal rules, procedures, policies or bylaws. The appointment of a Labor Trustee may be terminated, at any time, by the president of SEIU Healthcare 775NW according to SEIU Healthcare 775NW's internal rules, procedures, policies or bylaws. Form 990, Part VI, Section B, line 11 The Form 990 was prepared by the independent accounting firm SCHOEDEL & SCHOEDEL, Certified Public Accountants, PLLC from information provided by the third-party administrator and other consultants and advisors. Draft copies of the Trust's financial statements and Form 990 were first provided to the Trust's consultants and advisors, who reviewed the Form 990 for accuracy and completeness. Any questions, concerns or issues raised by the consultants and advisors were addressed and any necessary revisions were made to the Form 990. The revised Form 990 was then provided to the Board of Trustees for its review and approval. Any additional questions, concerns or issues raised by the Board of Trustees were addressed and any necessary revisions were made to the Form 990. The final version of the Form 990 was reviewed, approved and filed by the Board of Trustees. Form 990, Part VI, Section B, line 12c A copy of the Trust's Conflict of Interest Policy has been distributed to each Trustee and other fiduciaries. At least annually, a fiduciary is obligated to disclose or update to the Board of Trustees a list of relatives as defined in the policy involved in any transaction, as well as the fiduciary's business or other interests in any transaction impacting Trust assets (except for the receipt of benefits under the terms of the trust and plan). Further, any fiduciary who has knowledge of any transaction that may arguably be restricted pursuant to the policy, and that has not been specifically permitted by ERISA Section 408 or Department of Labor administrative exemptions, is obligated to disclose such information to the Board of Trustees. The Board of Trustees will investigate any actual or potential conflicts of interest. If the Board of Trustees determines that a conflict exists with respect to a fiduciary, it will prohibit the fiduciary from discussions, votes, or attempts to influence the issue or decision that is impacted. There are no compensated management officials, officers or key employees of the organization. If the organization had such compensated individuals, policies and procedures would be developed to determine compensation. Form 990, Part VI, Section C, line 19 The Trust's governing documents, conflict of interest policy, financial statements, and Form 990 are available to the general public upon written request sent to Benefit Solutions, Inc. at P.O. Box 6, Mukilteo, WA 98275. Coastal CAP 117 East Third Aberdeen WA 98520 Home care services WA 501(c)(3) Line 7 N/A 0 Concerned Citizens PO Box 1787 Forks WA 98331 911156809 Home care services WA 501(c)(3) Line 7 N/A 0 Korean Women's Association 123 E 96th Street Tacoma WA 98445 Home care services WA 501(c)(3) Line 9 N/A 0 SEIU Healthcare NW Training Partnership 635 Andover Park West Suite 200 Tukwila WA 98188 To provide comprehensive training, support, and career development benefits. WA 501(c)(3) Line 2 N/A 0 SEIU Healthcare 775NW 33615 First Way S Suite A Federal Way WA 98003 Local union representing home care and nursing home workers. WA 501(c)(5) N/A 0 SEIU 925 Multiemployer Health Benefits Trust PO Box 6 Mukilteo WA 98275 To provide health benefits for participants WA 501(c)(9) N/A 0 State of Washington - Department of Social and Health Services PO Box 45842 Olympia WA 98504 To improve safety and health of individuals, families, and communities. WA N/A 0 Visiting Nurse HomeCare 600 Birchwood Avenue Suite 100 Bellingham WA 98225 Home care services WA 501(c)(3) Line 9 N/A 0 AAA Residential Services 16256 Military Rd S Suite 209 SeaTac WA 98188 Home care services WA N/A C 0 Addus Health Care 1121 N Argonne Road Spokane WA 99212 Home care services WA N/A C 0 Amicable Healthcare Inc 15220-B 32nd Avenue South SeaTac WA 99188 Home care services WA N/A S 0 Capital Opportunities PO Box 877 Bozeman MT 59771 Home care services MT N/A C 0 Catholic Community Services 100 23rd Ave S Seattle WA 98144 Home care services WA N/A S 0 CDM HomeCare Services 11818 S E Mill Plain Blvd Vancouver WA 98684 Home care services WA N/A C 0 Chesterfield Services Inc 703 Columbia Street Suite 200 Seattle WA 98104 Home care services WA N/A C 0 Lower Columbia Community Action Council 1526 Commerce Avenue Longview WA 98632 Home care services WA N/A C 0 Olympic Community Action Programs 803 West Park Avenue Port Townsend WA 98368 Home care services WA N/A C 0 ResCare of WA 747 St Helens Avenue Suite 200 Tacoma WA 98402 Home care services WA N/A C 0 Senior Life Resources Northwest 8656 West Gage Blvd Suite 301 Kennewick WA 99336 Home care services WA N/A C 0 Whatcom Counseling and Psychiatric Clinic 3645 E McLeod Road Bellingham WA 98226 Home care services WA N/A S 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 1