-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, PM3EfU9riKuUKwkaIOC6StJOZvICNl9Y+MAp9yVidnTPy3V6wRGR264roXNL0NvF FYrTn+/2nwWUaZgRhhOeug== 0001167966-04-000717.txt : 20040823 0001167966-04-000717.hdr.sgml : 20040823 20040823171907 ACCESSION NUMBER: 0001167966-04-000717 CONFORMED SUBMISSION TYPE: SC 13G PUBLIC DOCUMENT COUNT: 1 FILED AS OF DATE: 20040823 DATE AS OF CHANGE: 20040823 GROUP MEMBERS: HERITAGE ASSURANCE PARTNERS, L.P. GROUP MEMBERS: JOHN F. RAY SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: ASSURANCEAMERICA CORP CENTRAL INDEX KEY: 0000008497 STANDARD INDUSTRIAL CLASSIFICATION: FIRE, MARINE & CASUALTY INSURANCE [6331] IRS NUMBER: 870281240 STATE OF INCORPORATION: NV FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: SC 13G SEC ACT: 1934 Act SEC FILE NUMBER: 005-58867 FILM NUMBER: 04992540 BUSINESS ADDRESS: STREET 1: RIVER EDGE ONE SUITE 600 STREET 2: 5500 INTERSTATE NORTH PKWY CITY: ATLANTA STATE: GA ZIP: 30328 BUSINESS PHONE: 770 933 8911 MAIL ADDRESS: STREET 1: RIVER EDGE ONE SUITE 600 STREET 2: 5500 INTERSTATE NORTH PKWY CITY: ATLANTA STATE: GA ZIP: 30328 FORMER COMPANY: FORMER CONFORMED NAME: BRAINWORKS VENTURES INC DATE OF NAME CHANGE: 20001115 FORMER COMPANY: FORMER CONFORMED NAME: AURIC METALS CORP DATE OF NAME CHANGE: 19920703 FILED BY: COMPANY DATA: COMPANY CONFORMED NAME: HERITAGE FUND ADVISORS LLC CENTRAL INDEX KEY: 0001210547 IRS NUMBER: 011255492 STATE OF INCORPORATION: GA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: SC 13G BUSINESS ADDRESS: STREET 1: 3384 PEACHTREE ROAD NE STREET 2: SUITE 300 CITY: ATLANTA STATE: GA ZIP: 30326 BUSINESS PHONE: 4044190100 MAIL ADDRESS: STREET 1: 3384 PEACHTREE RD. N.E. STREET 2: SUITE 300 CITY: ATLANTA STATE: GA ZIP: 30326 SC 13G 1 a1305_sc13g.txt SCHEDULE 13G SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 ------------- SCHEDULE 13G (Rule 13d-102) INFORMATION TO BE INCLUDED IN STATEMENTS FILED PURSUANT TO RULE 13D-1(B), (C), AND (D) AND AMENDMENTS THERETO FILED PURSUANT TO RULE 13D-2(B) ASSURANCEAMERICA CORPORATION - -------------------------------------------------------------------------------- (NAME OF ISSUER) COMMON STOCK, PAR VALUE $0.01 - -------------------------------------------------------------------------------- (TITLE OF CLASS OF SECURITIES) 04621M102 - -------------------------------------------------------------------------------- (CUSIP NUMBER) AUGUST - -------------------------------------------------------------------------------- (DATE OF EVENT WHICH REQUIRES FILING OF THIS STATEMENT) Check the appropriate box to designate the rule pursuant to which this Schedule is filed: | | Rule 13d-1(b) |X| Rule 13d-1(c) | | Rule 13d-1(d) - -------------------- * The remainder of this cover page shall be filled out for a reporting person's initial filing on this form with respect to the subject class of securities, and for any subsequent amendment containing information which would alter the disclosures provided in a prior cover page. The information required in the remainder of this cover page shall not be deemed to be "filed" for the purpose of Section 18 of the Securities Exchange Act of 1934 or otherwise subject to the liabilities of that section of the Act but shall be subject to all other provisions of the Act (however, see the NOTES). (Continued on following pages) (Page 1 of 10 Pages) - -------------------------------------------------------------------------------- CUSIP NO. 04621m102 13G Page 2 of 10 Pages - -------------------------------------------------------------------------------- ________________________________________________________________________________ 1. NAME OF REPORTING PERSONS I.R.S. IDENTIFICATION NO. OF ABOVE PERSONS (ENTITIES ONLY) Heritage Fund Advisors, LLC ________________________________________________________________________________ 2. CHECK THE APPROPRIATE BOX IF A MEMBER OF A GROUP* (a) [_] (b) [_] ________________________________________________________________________________ 3. SEC USE ONLY ________________________________________________________________________________ 4. CITIZENSHIP OR PLACE OF ORGANIZATION State of Georgia, United States of America ________________________________________________________________________________ NUMBER OF 5. SOLE VOTING POWER SHARES N/A _________________________________________________________________ BENEFICIALLY 6. SHARED VOTING POWER OWNED BY 4,260,000 shares of Common Stock _________________________________________________________________ EACH 7. SOLE DISPOSITIVE POWER REPORTING N/A _________________________________________________________________ PERSON 8. SHARED DISPOSITIVE POWER WITH 4,260,000 shares of Common Stock ________________________________________________________________________________ 9. AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH REPORTING PERSON 4,260,000 shares of Common Stock ________________________________________________________________________________ 10. CHECK BOX IF THE AGGREGATE AMOUNT IN ROW (9) EXCLUDES CERTAIN SHARES* [_] ________________________________________________________________________________ 11. PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW 9 8.6% of the outstanding Common Stock ________________________________________________________________________________ 12. TYPE OF REPORTING PERSON* OO (Limited Liability Company) ________________________________________________________________________________ - -------------------------------------------------------------------------------- CUSIP NO. 04621m102 13G Page 3 of 10 Pages - -------------------------------------------------------------------------------- ________________________________________________________________________________ 1. NAME OF REPORTING PERSONS I.R.S. IDENTIFICATION NO. OF ABOVE PERSONS (ENTITIES ONLY) Heritage Assurance Partners, L.P. ________________________________________________________________________________ 2. CHECK THE APPROPRIATE BOX IF A MEMBER OF A GROUP* (a) [_] (b) [_] ________________________________________________________________________________ 3. SEC USE ONLY ________________________________________________________________________________ 4. CITIZENSHIP OR PLACE OF ORGANIZATION State of Georgia, United States of America ________________________________________________________________________________ NUMBER OF 5. SOLE VOTING POWER SHARES N/A _________________________________________________________________ BENEFICIALLY 6. SHARED VOTING POWER OWNED BY 4,260,000 shares of Common Stock _________________________________________________________________ EACH 7. SOLE DISPOSITIVE POWER REPORTING N/A _________________________________________________________________ PERSON 8. SHARED DISPOSITIVE POWER WITH 4,260,000 shares of Common Stock ________________________________________________________________________________ 9. AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH REPORTING PERSON 4,260,000 shares of Common Stock ________________________________________________________________________________ 10. CHECK BOX IF THE AGGREGATE AMOUNT IN ROW (9) EXCLUDES CERTAIN SHARES* [_] ________________________________________________________________________________ 11. PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW 9 8.6% of the outstanding Common Stock ________________________________________________________________________________ 12. TYPE OF REPORTING PERSON* PN (Limited Partnership) ________________________________________________________________________________ - -------------------------------------------------------------------------------- CUSIP NO. 04621m102 13G Page 4 of 10 Pages - -------------------------------------------------------------------------------- ________________________________________________________________________________ 1. NAME OF REPORTING PERSONS I.R.S. IDENTIFICATION NO. OF ABOVE PERSONS (ENTITIES ONLY) John F. Ray ________________________________________________________________________________ 2. CHECK THE APPROPRIATE BOX IF A MEMBER OF A GROUP* (a) [_] (b) [_] ________________________________________________________________________________ 3. SEC USE ONLY ________________________________________________________________________________ 4. CITIZENSHIP OR PLACE OF ORGANIZATION State of Georgia, United States of America ________________________________________________________________________________ NUMBER OF 5. SOLE VOTING POWER SHARES Beneficial ownership of all shares of Common Stock disclaimed. _________________________________________________________________ BENEFICIALLY 6. SHARED VOTING POWER OWNED BY Beneficial ownership of all shares of Common Stock disclaimed. _________________________________________________________________ EACH 7. SOLE DISPOSITIVE POWER REPORTING Beneficial ownership of all shares of Common Stock disclaimed. _________________________________________________________________ PERSON 8. SHARED DISPOSITIVE POWER WITH Beneficial ownership of all shares of Common Stock disclaimed. ________________________________________________________________________________ 9. AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH REPORTING PERSON Beneficial ownership of all shares of Common Stock disclaimed. ________________________________________________________________________________ 10. CHECK BOX IF THE AGGREGATE AMOUNT IN ROW (9) EXCLUDES CERTAIN SHARES* [_] ________________________________________________________________________________ 11. PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW 9 N/A ________________________________________________________________________________ 12. TYPE OF REPORTING PERSON* IN ________________________________________________________________________________ Item 1. (a) NAME OF ISSUER: AssuranceAmerica Corporation. (b) ADDRESS OF ISSUER'S PRINCIPAL EXECUTIVE OFFICES: 5500 Interstate North Pkwy., Suite 600, Atlanta, Georgia 30328 Item 2. (a) NAME OF PERSON FILING: Heritage Assurance Partners, L.P. Heritage Fund Advisors, LLC John F. Ray (b) ADDRESS OF PRINCIPAL BUSINESS OFFICE OR, IF NONE, RESIDENCE: For all persons filing: 3353 Peachtree Road, N.E., Suite 1040 Atlanta, GA 30326 (c) CITIZENSHIP: For all persons filing: State of Georgia, United States of America (d) TITLE OF CLASS OF SECURITIES: Common Stock, Par Value $0.01 Per Share (e) CUSIP NUMBER: 04621m102 Item 3. IF THIS STATEMENT IS FILED PURSUANT TO RULE 13D-1(B), OR 13D-2(B) OR (C), CHECK WHETHER THE PERSON FILING IS A: (a) | | Broker or dealer registered under section 15 of the Act (15 U.S.C. 78o). (b) | | Bank as defined in section 3(a)(6) of the Act (15 U.S.C. 78c). (c) | | Insurance company as defined in section 3(a)(19) of the Act (15 U.S.C. 78c). (d) | | Investment company registered under section 8 of the Investment Company Act of 1940 (15 U.S.C 80a-8). (e) |X| An investment adviser in accordance with ss.240.13d-1 (b)(1)(ii)(E); (Page 5 of 10 Pages) (f) | | An employee benefit plan or endowment fund in accordance with ss.240.13d-1(b)(1)(ii)(F); (g) | | A parent holding company or control person in accordance with ss. 240.13d-1(b)(1)(ii)(G); (h) | | A savings associations as defined in Section 3(b) of the Federal Deposit Insurance Act (12 U.S.C. 1813); (i) | | A church plan that is excluded from the definition of an investment company under section 3(c)(14) of the Investment Company Act of 1940 (15 U.S.C. 80a-3); (j) | | Group, in accordance with ss.240.13d-1(b)(1)(ii)(J). Heritage Fund Advisors, LLC is an investment advisor in accordance with ss.240.13d-1(b)(1)(ii)(E). Item 4. OWNERSHIP.
Heritage Assurance Heritage Fund Partners, L.P. Advisors, LLC John F. Ray ------------------ -------------- ----------- (a) Amount Beneficially Owned: 4,260,000 4,260,000 Disclaimed (b) Percent of Class: 8.6% 8.6% N/A (c) Number of Shares to Which Reporting Person Has: (i) Sole Voting Power: N/A N/A N/A (ii)Shared Voting Power: 4,260,000 4,260,000 Disclaimed (iii) Sole Dispositive Power: N/A N/A N/A (iv)Shared Dispositive Power: 4,260,000 4,260,000 Disclaimed
The reported shares (4,260,000) represent the shares of Common Stock into which the shares of unregistered Series A Convertible Preferred Stock (426,000) are convertible into pursuant to a 10:1 conversion ratio as set forth in the issuer's articles of incorporation. The reported shares are owned directly by Heritage Assurance Partners, L.P. ("HAP"), whose general partner is Heritage Fund Advisors, LLC, an investment advisor (the "General Partner"). The General Partner could be deemed to be an indirect beneficial owner of the reported shares, and could be deemed to share such beneficial ownership with HAP. (Page 6 of 10 Pages) John F. Ray is the sole manager of the General Partner, and could be deemed to be an indirect beneficial owner of the reported shares. He could be deemed to share such indirect beneficial ownership with the General Partner and HAP. Messr. Ray expressly disclaims beneficial ownership of the reported shares, and the filing of this report shall not be deemed to be an admission that he is a beneficial owner of the reported shares for purposes of Section 13(d) of the Securities Exchange Act of 1934 or for any other purpose. Item 5. OWNERSHIP OF FIVE PERCENT OR LESS OF A CLASS. If this statement is being filed to report the fact that as of the date hereof the reporting person has ceased to be the beneficial owner of more than five percent of the class of securities, check the following. Item 6. OWNERSHIP OF MORE THAN FIVE PERCENT ON BEHALF OF ANOTHER PERSON. Heritage Capital Advisors, LLC is the sole member of the General Partner, and has the right to receive or the power to direct the receipt of dividends from, or the proceeds from the sale of, the reported shares beneficially owned indirectly by the General Partner. Item 7. IDENTIFICATION AND CLASSIFICATION OF THE SUBSIDIARY WHICH ACQUIRED THE SECURITY BEING REPORTED ON BY THE PARENT HOLDING COMPANY OR CONTROL PERSON. Not applicable. Item 8. IDENTIFICATION AND CLASSIFICATION OF MEMBERS OF THE GROUP. Not applicable. Item 9. NOTICE OF DISSOLUTION OF GROUP. Not applicable. Item 10. CERTIFICATION. By signing below I certify that, to the best of my knowledge and belief, the securities referred to above were not acquired and are not held for the purpose of or with the effect of changing or influencing the control of the issuer of the securities and were not acquired and are not held in connection with or as a participant in any transaction having that purpose or effect. (Page 7 of 10 Pages) SIGNATURE After reasonable inquiry and to the best of my knowledge and belief, the undersigned certify that the information set forth in this Statement is true, complete and correct. Date: August 23, 2004 HERITAGE ASSURANCE PARTNERS, L.P. By: Heritage Fund Advisors, LLC, General Partner By: /S/ J. WESLEY GRACE --------------------------------- Name: J. Wesley Grace Title: Treasurer Date: August 23, 2004 HERITAGE FUND ADVISORS, LLC By: /S/ J. WESLEY GRACE --------------------------------- Name: J. Wesley Grace Title: Treasurer Date: August 23, 2004 /S/ JOHN F. RAY ------------------------------------- John F. Ray (Page 8 of 10 Pages) Exhibit Index Exhibit 1 Joint Filing Agreement dated as of August 23, 2004, by and among Heritage Assurance Partners, L.P.; Heritage Fund Advisors, LLC; and John F. Ray. (Page 9 of 10 Pages) EXHIBIT I JOINT FILING AGREEMENT and POWER OF ATTORNEY Pursuant to Rule 13d-1(k), the undersigned hereby agree that the attached Schedule 13G (including any amendments thereto) is filed on behalf of each of them. Each of the undersigned hereby makes, constitutes, and appoints J. Wesley Grace and John F. Ray, and each of them acting alone, their true and lawful attorney-in-fact, with full power of substitution and resubstitution, for it in any and all capacities to execute and cause to be filed with the Securities and Exchange Commission any and all amendments to this Schedule 13G, together with exhibits to any such amendments and other documents in connection therewith, and hereby ratifies and confirms all that said attorney-in-fact or said attorney-in-fact's substitute or substitutes may do or cause to be done by virtue hereof. Date: August 23, 2004 HERITAGE ASSURANCE PARTNERS, L.P. By: Heritage Fund Advisors, LLC, General Partner By: /S/ J. WESLEY GRACE ---------------------------------------- Name: J. Wesley Grace Title: Treasurer Date: August 23, 2004 HERITAGE FUND ADVISORS, LLC By: /S/ J. WESLEY GRACE ---------------------------------------- Name: J. Wesley Grace Title: Treasurer Date: August 23, 2004 /S/ JOHN F. RAY ---------------------------------------- John F. Ray (Page 10 of 10 Pages) -----END PRIVACY-ENHANCED MESSAGE-----