2013-02-28T18:27:55-06:00 2012-04-30 522385296 LINDQUIST LLP 5000 EXECUTIVE PARKWAY SUITE 400 SAN RAMON CA 94583 990 2011-05-01 946284253 JOINT BENEFIT TRUST JOIN 9254497070 4160 DUBLIN BLVD NO 400 DUBLIN CA 94568 JOHN HURLEY 9254497070 2013-02-28 1 JOSEPH M THIERMANN P01066616 9252779100 2011 2016-03-07 17:11:31Z JOHN HURLEY 4160 DUBLIN BLVD NO 400 DUBLIN CA 94568 103560747 0 X N/A X 1972 CA PROVIDE HEALTH AND WELFARE BENEFITS 8 0 0 0 0 0 0 0 47888407 55137507 131477 257010 32260 3754 48052144 55398271 0 0 50225523 50646041 0 0 0 0 0 5656562 5937102 55882085 56583143 -7829941 -1184872 25019860 23091030 10918629 10231250 14101231 12859780 TO PROVIDE HEALTH AND WELFARE BENEFITS. 0 0 HEALTH AND WELFARE BENEFITS PROVIDED UNDER COLLECTIVE BARGAINING FOR PARTICIPANTS. 0 0 0 0 0 0 0 0 0 1 0 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 0 1 1247 0 1 0 0 0 0 0 0 0 X 8 0 0 1 0 0 0 0 0 1 0 0 0 1 1 1 1 1 1 0 0 0 X HEALTH SERVICE & BENEFIT ADMINISTRATORS 9258337300 4160 DUBLIN BLVD SUITE 400 DUBLIN CA 94588 X ASHLEY ALVARADO 2.00 X 0 0 0 JOHN HURLEY 2.00 X 0 0 0 CRESCENCIO DIAZ 2.00 X 0 0 0 RICHARD EHRLER 2.00 X 0 0 0 ADAM OCHOA 2.00 X 0 0 0 RICHARD W MUTO 2.00 X 0 0 0 PABLO BARRERA 2.00 X 0 0 0 TOM NETT 2.00 X 0 0 0 LUPE JUAREZ - PAST 2.00 X 0 0 0 JOHN HAILSTONE - PAST 2.00 X 0 0 0 0 0 0 0 0 0 0 HEALTH SERVICE BENEFIT ADMIN 4160 DUBLIN BLVD SUITE 400 DUBLIN CA 94588 ADMINISTRATOR FEES 3199396 BLUE CROSS OF CALIFORNIA DEPARTMENT 5812 LOS ANGELES CA 900745812 PPO NETWORK FEE 704463 AMERICAN HEALTH WAYS PO BOX 166718 ATLANTA GA 303687180 ADMINISTRATION FEES 439256 BEESON TAYER & BODINE 483 NINTH STREET OAKLAND CA 94607 LEGAL FEES 214351 THE SEGAL COMPANY 100 MONTGOMERY STREET SUITE 500 SAN FRANCISCO CA 94104 ACTUARIAL AND CONSULTING FEES 204426 5 EMPLOYER CONTRIBUTIONS 900099 51968644 51968644 EMPLOYEE CONTRIBUTIONS 900099 2804646 2804646 PRESCRIPTION REBATE IN 900099 306353 306353 STOP-LOSS RECOVERY 900099 57864 57864 55137507 299752 299752 48119734 48162476 -42742 -42742 -42742 OTHER INCOME 900099 3754 3754 3754 55398271 55141261 0 257010 50646041 3071995 268256 129315 47163 1904277 377891 1020 82312 36240 MISC. EXPENSES 18633 56583143 1556912 1018808 4921323 4120618 34015 24991 6966 6966 0 0 18038584 17233543 197700 469026 495370 25019860 23091030 402824 410754 10515805 9820496 10918629 10231250 X 0 0 0 0 14101231 12859780 14101231 12859780 25019860 23091030 X -1184872 -56579 X X 0 1 1 X 0 6966 6966 0 0 ACCUMULATED ELIGIBILITY CREDITS 3825496 GROUP INS PREMIUMS PAYABLE 1408000 CLAIMS PAYABLE AND IBNR 4587000 9820496 55398271 56583143 -1184872 -56579 -695309 -751888 -1936760 55294529 -56579 -56579 55351108 47163 47163 55398271 57231289 0 57231289 47163 -695309 -648146 56583143 PART XI, LINE 8 - OTHER ADJUSTMENTS: CHANGES IN BENEFIT OBLIGATIONS -695,309. PART XIII, LINE 4B - OTHER ADJUSTMENTS: CHANGES IN BENEFIT OBLIGATIONS PART X, LINE 2: THE PLAN'S ADMINISTRATOR HAS ANALYZED THE TAX POSITIONS TAKEN BY THE PLAN AND HAS CONCLUDED THAT AS OF APRIL 30, 2012, 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'S ADMINISTRATOR BELIEVES IT IS NO LONGER SUBJECT TO INCOME TAX EXAMINATIONS FOR THE YEARS PRIOR TO THE FISCAL YEAR ENDING APRIL 30, 2009. FORM 990, PART VI, SECTION A, LINE 3 THE TRUST HAS CONTRACTED WITH HEALTH SERVICE BENEFIT ADMINISTRATORS, INC. TO PROVIDE ADMINISTRATIVE SERVICES FOR THE ORGANIZATION. FORM 990, PART VI, SECTION A, LINE 8B THERE IS NO COMMITTEE WITH AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. FORM 990, PART VI, SECTION B, LINE 11 A COPY OF THE FORM 990 WAS PROVIDED TO ALL MEMBERS OF THE GOVERNING BODY FOR REVIEW BEFORE IT WAS FILED. FORM 990, PART VI, SECTION B, LINE 12C AT LEAST ANNUALLY, TRUSTEES AND OTHER INDIVIDUALS SUBJECT TO THE CONFLICT OF INTEREST POLICY WILL BE ASKED TO DISCLOSE IN WRITING ANY RELATIONSHIPS OR INTERESTS THAT COULD GIVE RISE TO A CONFLICT. FORM 990, PART VI, SECTION C, LINE 19 ALL GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC UPON REQUEST. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -56,579. FORM 990, PART XII, LINE 2C: THE BOARD ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDITED FINANCIAL STATEMENTS AND FOR THE SELECTION OF THE INDEPENDENT ACCOUNTANT. THIS PROCESS HAS NOT CHANGED. HEALTH SERVICES FOUNDATION 160 AIRWAY BOULEVARD LIVERMORE CA 94551 942260587 TO PROVIDE MEDICAL EXAMINATIONS CA 501(C)(4) N/A N/A 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 APRIL 30, 2012 THERE ARE APPROXIMATELY 17 EMPLOYERS THAT CONTRIBUTE TO THE TRUST. THE ADMINISTRATIVE OFFICE MAINTAINS A DATABASE OF THESE CONTRIBUTING EMPLOYERS, INCLUDING NAMES, ADDRESSES AND OTHER CONTACT INFORMATION. HOWEVER, CERTAIN INFORMATION THAT IS REQUIRED TO BE REPORTED ON SCHEDULE R SUCH AS EMPLOYER IDENTIFICATION NUMBERS AND LEGAL STRUCTURE (CORPORATION, PARTNERSHIP, ETC.) FOR EACH CONTRIBUTING EMPLOYER IS NOT ON FILE WITH THE ADMINISTRATIVE OFFICE AND IT COULD NOT BE REASONABLY OBTAINED. AS A RESULT, THE CONTRIBUTING EMPLOYERS HAVE NOT BEEN INCLUDED ON SCHEDULE R.