FEC Form 1 for American Medical Security Inc. PACForm 1 for American Medical Security Inc. PAC

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-12809

1. American Medical Security Inc. PAC

3100 AMS Boulevard
P.O. Box 19032
Green Bay, WI 543079032
Email: amsinfo@amschoices.com

2. Date: 03/19/2001

3. FEC Committee ID #: C00283457 This committee is a Separate Segregated Fund

Affiliated Committees/Organizations

Blue Cross & Blue Shield United of Wisconsin
401 West Michigan Street
Milwaukee, Wisconsin 53203
Relationship: Connected Organizati
Organization Type: Corporation

American Medical Security Inc.
3100 AMS Boulevard
P.O. Box 19032
Green Bay, Wisconsin 543079032
Relationship: Connected Organizati
Organization Type: Corporation

Custodian of Records:

Treasurer:

Gary Guengerich
297 Desplaines Road
De Pere, Wisconsin 54115

Designated Agent(s):

Banks or Depositories

Bank One - Green Bay
P.O. Box 19029
Green Bay, Wisconsin 54307

Signed: Gary Guengerich
Date Signed: 03/19/2001
Official Committee URL: www.amschoices.com

(End FEC FORM 1)

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