FEC FORM 1
STATEMENT OF ORGANIZATION
FILING FEC-157964
1. American Medical Security Group Inc. PAC
3100 AMS BoulevardP.O. Box 19032
Green Bay, WI 543079032
Fax: 9206619746
Email: www.eAMS.com
2. Date: 01/06/2005
3. FEC Committee ID #: C00283457 This committee is a Separate Segregated FundAffiliated Committees/Organizations
American Medical Security Group Inc.3100 AMS Boulevard
PO Box 19032
Green Bay, Wisconsin 543079032
Relationship: Connected Organizati
Organization Type: Corporation
Committee ID# C00240903
PacifiCare Health Systems Inc. Employe
M/S CY20-536
5995 Plaza Drive
Cypress, California 90630
Relationship: Affiliated Committee
Organization Type: Corporation
Custodian of Records:
Timothy Moore1821 South Sunkist Circle
De Pere, WI 54115
Title: President
Phone # (920) 661-3075
Treasurer:
James Prochnow1090 Coprinus Court
Green Bay, Wisconsin 54313
Title: Treasurer
Phone # (920) 661-2038
Designated Agent(s):
Timothy Moore1821 South Sunkist Circle
De Pere, Wisconsin 54115
Title: President
Phone # (920) 661-3075
James Prochnow
1090 Coprinus Court
Green Bay, Wisconsin 54313
Title: Treasurer
Phone # (920) 661-2038
Patrick O'Connell
167 Brule Road
DePere, Wisconsin 54115
Title: Assistant Treasurer
Phone # (920) 661-2479
William May
2582 Misty River Lane
De Pere, Wisconsin 54115
Title: VP & Secretary
Phone # (920) 661-2751
Cheryl Thomson
222 Forest Drive
Sobieski, Wisconsin 54171
Title: Assistant Secretary
Phone # (920) 661-3078
Banks or Depositories
Bank One - Green BayP.O. Box 19029
Green Bay, Wisconsin 54307