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FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-954603

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1. Health Care Service Corporation Employees' Political Action Committee

    300 E. Randolph
    Legal Department
    Chicago, IL 60601
    Email: stutzm@bcbsil.com;Ariana_Voigt@bcbsil.com

2. Date: 10/02/2014

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:

Mary Lou Stutz
Health Care Service Corporation
300 E. Randolph, Legal Department
Chicago, IL 60601
Title: Asst. Treasurer
Phone # (312) 653-6363

Treasurer:

Gerard T. Mallen
Health Care Service Corporation
300 E. Randolph, Treasury Operatio
Chicago, Illinois 60601
Title: Treasurer
Phone # (312) 653-6649

Designated Agent(s):

Mary Lou Stutz
Health Care Service Corporation
300 E. Randolph, Legal Department
Chicago, Illinois 60601
Title: Asst. Treasurer
Phone # (312) 653-6363

Banks or Depositories

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

Signed: Gerard T. Mallen
Date Signed: 10/08/2014

(End FEC FORM 1)

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