Nebraska Legislature - Lobbyist Reporting Application

FORM
A

NEBRASKA LEGISLATURE
APPLICATION FOR REGISTRATION AS A LOBBYIST

Jan 2, 2024

Clerk of the Legislature
Room 2014, State Capitol
PO Box 94604
Lincoln, NE 68509-4604
Phone: (402) 471-2608

For Calendar Year of:

Amended Registration

Lobbyist Registration Fee:
{49-1480.01}

Compensated

$200.00

(If you are a salaried employee of your principal, you are a compensated lobbyist.)

Not Compensated

$15.00

(File a Form E for quarterly report exemption. You are not exempt from the Form D Activity Report.)

PLEASE FILL IN ALL BLANKS

LOBBYIST {49-1480(1)}

Name

Blake, Jeremiah

Office Address (Street, Box, or Route)

1919 Aksarben Drive

Permanent Residence (Street, Box, or Route)

6033 S 78th Street

City

Omaha

State

Zip

68180

City

Lincoln

State

Zip

68516

Office Phone

(402) 982-8926

Home Phone

(402) 261-8778

Email Address

jeremiah.blake@nebraskablue.com

PRINCIPAL {49-1480(2)}

Name

Blue Cross and Blue Shield of Nebraska

Office Phone

(402) 982-7000

Office Address (Street, Box, or Route)

1919 Aksarben Drive

Official to Whom Lobbyist is Accountable

Cameron Arch

City

Omaha

State

Zip

68180

Nature of Business {49-1480(3)}

Insurance

AMOUNTS GIVEN or to be given to lobbyist as compensation or reimbursement of lobbying: {49-1480(3)}. Please state the basis for your compensation.
1,500.00 Per Month

IDENTIFICATION of MATTERS on which principal or lobbyist expects to lobby: {49-1480(5)} Health insurance, health care, general business issues

Description of industry, trade, profession, or interests and groups represented by the principal:
Insurance

Names and addresses of principal's officers:

Cameron Arch
1919 Aksarben Dr
Omaha, NE 68180

GIVE NAME and ADDRESS of any OFFICIAL in the Legislative or Executive Branch and of any members of any such official's staff or immediate family who is employed by you or by anyone acting on your behalf: {49-1480(8)}

None

I certify that all information presented in this form is accurate to the best of my knowledge.

Jeremiah Blake

Lobbyist Name

Jan 2, 2024

Date