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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-484688

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1. LUMBERMENS INSURANCE CAMPAIGN FUND

    NOTE:Commmittee Name is different than previously reported

    Lumbermens Mutual Group
    1 Corporate Drive, Suite 200
    Lake Zurich, IL 60047

    NOTE: Address is different than previously reported

2. Date: 07/21/2010

3. FEC Committee ID #: C00009035 This committee is a separate segregated fund. Its connected organization is a Corporation

Affiliated Committees/Organizations

Lumbermens Mutual Casualty Company
1 Corporate Drive, Suite 200
Lake Zurich, Illinois 60047
Affiliated Relationship Code: Connected Organization

Custodian of Records:

John K Conway
Lumbermens Mutual Group
1 Corporate Drive, Suite 200
Lake Zurich, IL 60047
Title: Secretary/Treasurer
Phone # (847) 320-3262

Treasurer:

John K Conway
Lumbermens Mutual Group
1 Corporate Drive, Suite 200
Lake Zurich, Illinois 60047
Title: Secretary/Treasurer
Phone # (847) 320-3262

Designated Agent(s):

Raymond J Jilek
Lumbermens Mutual Group
1 Corporate Drive, Suite 200
Lake Zurich, Illinois 60047
Title: Assistant Treasurer
Phone # (847) 320-3595

Banks or Depositories

American Chartered Bank
459 So. Rand Road
Lake Zurich, Illinois 60047

Signed: John K Conway
Date Signed: 07/27/2010

(End FEC FORM 1)

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