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

FEC FORM 1

STATEMENT OF ORGANIZATION

FILING FEC-184083

1. American Medical Security Group Inc. PAC

3100 AMS Boulevard
P.O. Box 19032
Green Bay, WI 543079032
Fax: 9206619746
Email: www.eAMS.com

2. Date: 08/10/2005

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

Affiliated Committees/Organizations

Committee ID# C00240903
PacifiCare Health Systems Inc. Employees' Political Action Committee
M/S CY20-536
5995 Plaza Drive
Cypress, California 90630
Relationship: Affiliated Committee
Organization Type: Corporation

Custodian of Records:

James Prochnow
1090 Coprinus Court
Green Bay, WI 54313
Title: Recordkeeper
Phone # (920) 661-2038

Treasurer:

James Prochnow
1090 Coprinus Court
Green Bay, Wisconsin 54313
Title: Treasurer
Phone # (920) 661-2038

Designated Agent(s):

James Prochnow
1090 Coprinus Court
Green Bay, Wisconsin 54313
Title: Treasurer
Phone # (920) 661-2038

Cheryl Thomson
222 Forest Drive
Sobieski, Wisconsin 54171
Title: Assistant Secretary
Phone # (920) 661-3078

Banks or Depositories

Signed: James Prochnow
Date Signed: 08/10/2005
Official Committee URL: www.amsinfo@eAMS.com
Official Committee FAX: 9206619746

(End FEC FORM 1)

Generated Wed Jul 17 17:40:46 2024