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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-1204702

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1. Health Care Service Corporation Employees' Political Action Committee

    300 E. Randolph
    Legal Department
    Chicago, IL 60601
    Email: Bailey_Anderson@bcbsil.com

    NOTE: Email address is different than previously reported

2. Date: 01/31/2018

3. FEC Committee ID #: C00199711 This committee is a separate segregated fund. Its connected organization is a Corporation
     In addition, this committee is a Lobbyist/Registrant PAC.

Affiliated Committees/Organizations

Health Care Service Corporation
300 E. Randolph
Chicago, Illinois 60601
Affiliated Relationship Code: Connected Organization

Custodian of Records:

TJ Spohnholtz
Health Care Service Corporation
300 E. Randolph, Legal Department
Chicago, IL 60601
Title: Treasurer
Phone # (202) 249-7221

Treasurer:

TJ Spohnholtz
Health Care Service Corporation
300 E. Randolph, Legal Department
Chicago, Illinois 60601
Title: Treasurer
Phone # (202) 249-7221

Designated Agent(s):

Chris Swanson
Health Care Service Corporation
300 E. Randolph, Treasury Operatio
Chicago, Illinois 60601
Title: Ass.t Treasurer
Phone # (202) 249-7221

Chris Swanson
Health Care Service Corporation
300 E. Randolph, Treasury Operatio
Chicago, Illinois 60601
Title: Ass.t Treasurer
Phone # (202) 249-7221

Banks or Depositories

Northern Trust
50 S. LaSalle St.
Chicago, Illinois 60603

Signed: TJ Spohnholtz
Date Signed: 01/31/2018

(End FEC FORM 1)

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