2013-11-08T18:41:05-06:00 2012-12-31 990155373 LEMKE CHINEN & TANAKA CPA INC 210 WARD AVE SUITE 336 HONOLULU HI 968144012 990 2012-01-01 010757287 UFCW - HAWAII FOOD EMPLOYERS HEALTH & WELFARE TRUST FUND UFCW 8088417575 200 N VINEYARD BLVD STE 100 HONOLULU HI 96817 FRANK JORGENSENPATRICK LOO 8088417575 2013-10-16 1 TERRY TAKAKI P00036112 8085336254 2012 2016-02-24 21:20:13Z FRANK JORGENSENPATRICK L 200 N VINEYARD BLVD STE 100 HONOLULU HI 96817 17429213 0 X N/A X 2002 HI TO PROVIDE HEALTH & WELFARE BENEFITS TO ELIGIBLE PARTICIPANTS AND THEIR DEPENDENTS. 4 4 0 0 0 0 0 0 9145953 9731935 120681 121333 149418 102797 9416052 9956065 0 0 9766677 10060719 0 0 0 0 0 725952 820883 10492629 10881602 -1076577 -925537 11317006 10395112 15993 19636 11301013 10375476 TO PROVIDE HEALTH & WELFARE BENEFITS TO ELIGIBLE PARTICIPANTS AND THEIR DEPENDENTS. 0 0 7702593 TO PROVIDE SELF-INSURED HEALTH AND WELFARE BENEFITS TO ELIGIBLE PARTICIPANTS, THEIR DEPENDENTS, AND RETIREES (HMA $6,349,778, CATALYST $1,352,815). 2358126 TO PROVIDE HEALTH AND WELFARE BENEFITS TO ELIGIBLE PARTICIPANTS, THEIR DEPENDENTS, AND RETIREES BY PAYING MONTHLY INSURANCE PREMIUMS TO INSURANCE CARRIERS (KAISER PERMANENTE $1,240,651, HMSA $202,378, HAWAII DENTAL SERVICE $670,491, DCCH $48,789, PACIFIC GUARDIAN LIFE $56,963, CHIROPLAN $28,858, VISION SERVICE PLAN $109,996). 481268 TO PAY FOR ADMINISTRATIVE FEES FOR SELF-INSURED CLAIMS PROCESSING (HMA $434,421, CATALYST $46,847). 10541987 0 0 0 0 0 0 0 0 0 1 0 0 0 0 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 0 0 0 1 1 0 1 0 0 0 0 0 0 0 X 4 4 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 0 0 0 X HAWAII BENEFIT ADMINISTRATORS INC 8088417575 200 N VINEYARD BLVD STE 100 HONOLULU HI 96817 X FRANK JORGENSEN 1.00 X 0 0 0 PATRICK K LOO 1.00 X 0 0 0 CARL RAMNITZ - OLD 1.00 X 0 0 0 GWEN RULONA 1.00 X 0 0 0 PENNY SCHUMACHER - NEW 1.00 X 0 0 0 0 0 0 0 0 0 0 HMA INC 1440 KAPIOLANI BLVD HONOLULU HI 96814 CLAIMS ADMINISTRATOR 434421 HAWAII BENEFIT ADMINISTRATORS INC 200 N VINEYARD BLVD STE 100 HONOLULU HI 96817 THIRD PARTY ADMINISTRATOR 111506 2 EMPLOYER CONTRIBUTIONS 900099 9577806 9577806 SELF PAY & COBRA CONTRIB 900099 154129 154129 9731935 105207 105207 7489274 7473148 16126 16126 16126 EXPERIENCE REFUNDS/REBATES 900099 102285 102285 LIQUIDATED DAMAGES 900099 1645 1645 NET UNREALIZED GAINS 900099 -1133 -1133 102797 9956065 9851991 0 104074 10060719 111506 36068 25937 26742 69118 40651 7381 8250 8132 ADMINISTRATIVE FEES - M 481268 BANK FEES 5800 MISCELLANEOUS 30 10881602 2337548 1229876 918417 971701 1612 2015 8059429 8191520 11317006 10395112 15993 19636 15993 19636 X 11301013 10375476 0 0 0 0 11301013 10375476 11317006 10395112 -925537 0 X X 0 1 X 1 0 0 9827038 0 9827038 26742 102285 129027 9956065 10752575 -102285 -102285 10854860 26742 26742 10881602 PART XI, LINE 4B - OTHER ADJUSTMENTS: EXPERIENCE RFUNDS / REBATES 102,285. PART XII, LINE 2D - OTHER ADJUSTMENTS: EXPERIENCE REBATES -102,285. FORM 990, PART VI, SECTION B, LINE 11 ONE MANAGEMENT AND ONE LABOR TRUSTEE SIGN THE FORM 990. THE FORM 990 IS ALSO PROVIDED TO THE BOARD OF TRUSTEES AT THE QUARTERLY BOARD MEETINGS. FORM 990, PART VI, SECTION B, LINE 12C POLICY IS REVIEWED BY THE BOARD OF TRUSTEES ANNUALLY. FORM 990, PART VI, SECTION C, LINE 19 DOCUMENTS ARE AVAILABLE TO PUBLIC INSPECTION UPON REQUEST. FORM 990, PART XII, LINE 2C THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. BOARD OF TRUSTEES SELECT AN INDEPENDENT AUDITOR, AND REVIEW AND APPROVE THE FINANCIAL STATEMENTS.