-----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, UIjcSPkQL2Hg3GT1pRlyBeU4QDatmzggbmzQGwNRaMJlHTt2tjDDW4h0zmBMGvz7 KKQMZeobFOYTuf50NhbjmA== 0000912057-01-506483.txt : 20010409 0000912057-01-506483.hdr.sgml : 20010409 ACCESSION NUMBER: 0000912057-01-506483 CONFORMED SUBMISSION TYPE: SC 13D PUBLIC DOCUMENT COUNT: 1 FILED AS OF DATE: 20010402 GROUP MEMBERS: BLUE CROSS & BLUE SHIELD UNITED OF WISCONSIN GROUP MEMBERS: COBALT CORPORATION GROUP MEMBERS: WISCONSIN UNITED FOR HEALTH FOUNDATION INC SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: AMERICAN MEDICAL SECURITY GROUP INC CENTRAL INDEX KEY: 0000878897 STANDARD INDUSTRIAL CLASSIFICATION: HOSPITAL & MEDICAL SERVICE PLANS [6324] IRS NUMBER: 391431799 STATE OF INCORPORATION: WI FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: SC 13D SEC ACT: SEC FILE NUMBER: 005-41965 FILM NUMBER: 1591693 BUSINESS ADDRESS: STREET 1: 3100 AMS BLVD CITY: GREEN BAY STATE: WI ZIP: 54313 BUSINESS PHONE: 9206611111 MAIL ADDRESS: STREET 1: 3100 AMS BLVD CITY: GREEN BAY STATE: WI ZIP: 54313 FORMER COMPANY: FORMER CONFORMED NAME: UNITED WISCONSIN SERVICES INC /WI DATE OF NAME CHANGE: 19930328 FILED BY: COMPANY DATA: COMPANY CONFORMED NAME: WISCONSIN UNITED FOR HEALTH FOUNDATION INC CENTRAL INDEX KEY: 0001137437 STANDARD INDUSTRIAL CLASSIFICATION: [] IRS NUMBER: 391975149 STATE OF INCORPORATION: WI FILING VALUES: FORM TYPE: SC 13D BUSINESS ADDRESS: STREET 1: 10 E. DOTY CITY: MADISON STATE: WI ZIP: 53701 BUSINESS PHONE: 6082808235 SC 13D 1 a2044129zsc13d.txt SCHEDULE 13D UNITED STATES SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 SCHEDULE 13D UNDER THE SECURITIES EXCHANGE ACT OF 1934 American Medical Security Group, Inc. ----------------------------------------------------------- (Name of Issuer) Common Stock, No Par Value ----------------------------------------------------------- (Title of Class of Securities) 027 44P 101 --------------------------- (CUSIP Number) Thomas R. Hefty, President and Chief Executive Officer Cobalt Corporation 401 West Michigan Street, Milwaukee, Wisconsin 53203 ----------------------------------------------------------- (Name, Address and Telephone Number of Person Authorized to Receive Notices and Communications) March 23, 2001 --------------------------- (Date of Event which Requires Filing of this Statement) If the filing person has previously filed a statement on Schedule 13G to report the acquisition which is the subject of this Schedule 13D, and is filing this schedule because of Rule 13d-1(b)(3) or (4), check the following box. / / NOTE: Schedules filed in paper format shall include a signed original and five copies of the schedule, including all exhibits. See Section.240.13d-7 for other parties to whom copies are to be sent. *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 on 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 ("Act") 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). - ------------------------------------------ CUSIP NO. 682130 - ------------------------------------------ - -------------------------------------------------------------------------------- 1 NAME OF REPORTING PERSON WISCONSIN UNITED FOR HEALTH FOUNDATION, INC. COBALT CORPORATION BLUE CROSS & BLUE SHIELD UNITED OF WISCONSIN - -------------------------------------------------------------------------------- 2 CHECK THE APPROPRIATE BOX IF A MEMBER OF A GROUP* (a) |x|1 (b) | |2 - -------------------------------------------------------------------------------- 3 SEC USE ONLY - -------------------------------------------------------------------------------- 4 SOURCE OF FUNDS* NOT APPLICABLE - -------------------------------------------------------------------------------- 5 CHECK BOX IF DISCLOSURE OF LEGAL PROCEEDINGS IS REQUIRED PURSUANT TO ITEMS 2(D) or 2(E) |_|3 - -------------------------------------------------------------------------------- 6 CITIZENSHIP OR PLACE OF ORGANIZATION WISCONSIN UNITED FOR HEALTH FOUNDATION, INC. - WISCONSIN COBALT CORPORATION - WISCONSIN BLUE CROSS & BLUE SHIELD UNITED OF WISCONSIN - WISCONSIN - -------------------------------------------------------------------------------- NUMBER OF 7 SOLE VOTING POWER SHARES BENEFICIALLY BLUE CROSS & BLUE SHIELD UNITED OF WISCONSIN - 6,309,525 OWNED BY WISCONSIN UNITED FOR HEALTH FOUNDATION, INC. - 0 EACH COBALT CORPORATION - 0 REPORTING PERSON WITH ----------------------------------------------------------------- 8 SHARED VOTING POWER BLUE CROSS & BLUE SHIELD UNITED OF WISCONSIN - 0 WISCONSIN UNITED FOR HEALTH FOUNDATION, INC. - 0 COBALT CORPORATION - 0 ----------------------------------------------------------------- 9 SOLE DISPOSITIVE POWER BLUE CROSS & BLUE SHIELD UNITED OF WISCONSIN - 6,309,525 WISCONSIN UNITED FOR HEALTH FOUNDATION, INC. - 0 COBALT CORPORATION - 0 -2- ----------------------------------------------------------------- 10 SHARED DISPOSITIVE POWER BLUE CROSS & BLUE SHIELD UNITED OF WISCONSIN - 0 WISCONSIN UNITED FOR HEALTH FOUNDATION, INC. - 0 COBALT CORPORATION - 0 - -------------------------------------------------------------------------------- 11 AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH REPORTING PERSON BLUE CROSS & BLUE SHIELD UNITED OF WISCONSIN - 6,309,525 WISCONSIN UNITED FOR HEALTH FOUNDATION, INC. - 6,309,525 COBALT CORPORATION - 6,309,525 - -------------------------------------------------------------------------------- 12 CHECK BOX IF THE AGGREGATE AMOUNT IN ROW (11) EXCLUDES CERTAIN SHARES* |_|4 - -------------------------------------------------------------------------------- 13 PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW 11 44.4% - -------------------------------------------------------------------------------- 14 TYPE OF REPORTING PERSON* BLUE CROSS & BLUE SHIELD UNITED OF WISCONSIN -CO WISCONSIN UNITED FOR HEALTH FOUNDATION, INC. - CO COBALT CORPORATION - CO - -------------------------------------------------------------------------------- ITEM 1. SECURITY AND ISSUER This statement relates to shares of common stock, no par value per share ("Common Stock"), of American Medical Security, Inc. (the "Issuer"). The principal executive office of the Issuer is located at 3100 AMS Boulevard, Green Bay, WI 54313. ITEM 2. IDENTITY AND BACKGROUND (a) This statement is being filed by (i) Wisconsin United for Health Foundation, Inc.; 410 E. Doty Street, Madison, WI 53701; The Foundation is a Wisconsin social welfare organization; The Foundation is a Wisconsin non-stock corporation. (ii) Cobalt Corporation 401 West Michigan Street, Milwaukee, WI 53203 Cobalt is a publicly traded managed care company. Cobalt is a Wisconsin corporation. (iii) Blue Cross & Blue Shield United of Wisconsin, Inc. 401 West Michigan Street, Milwaukee, WI 53203 Blue Cross & Blue Shield United of Wisconsin is an insurance company and a Wisconsin corporation. -3- ITEM 3. SOURCE AND AMOUNT OF FUNDS OR OTHER CONSIDERATION N/A. The Foundation and Cobalt became beneficial owners of the Common Stock in connection with the conversion of Blue Cross & Blue Shield United of Wisconsin ("BCBSUW") from a Wisconsin service insurance corporation to a Wisconsin stock insurance corporation. BCBSUW previously owned the 6,309,525 shares of Common Stock as reported on BCBSUW's Report on Schedule 13G. In connection with the conversion, Cobalt became the owner of 100% of the issued and outstanding Common Stock of BCBSUW and the Foundation became the owner of 77.5% of the issued and outstanding Common Stock of Cobalt. Consequently, both the Foundation and Cobalt are deemed to be beneficial owners of the 6,309,525 shares of Common Stock owned by BCBSUW. ITEM 4. PURPOSE OF TRANSACTION Beneficial Ownership of the Common Stock by the Foundation and Cobalt occurred as described in Item 3. None of the reporting persons has any plans that would result in the occurrence of any of the events set forth in Item 4 of Schedule 13D. ITEM 5. INTEREST IN SECURITIES OF THE ISSUER a. Each of the Foundation, Cobalt and BCBSUW is deemed to be the beneficial owner of the 6,309,525 shares of the Common Stock owned by BCBSUW which represents 44.4% of the issued and outstanding Common Stock. b. (i) Number of Shares as to which the Foundation has: sole voting power - 0 shared voting power - 0 sole dispositive power - 0 shared dispositive power - 0 (ii) Number of shares to which Cobalt has: sole voting power - 0 shared voting power - 0 sole dispositive power - 0 shared dispositive power - 0 (iii) Number of shares to which BCBSUW has: sole voting power - 6,309,525 shared voting power - 0 sole dispositive power - 6,309,525 shared dispositive power - 0 -4- ITEM 6. CONTACTS, ARRANGEMENTS, UNDERSTANDINGS OR RELATIONSHIPS WITH RESPECT TO SECURITIES OF THE ISSUER None. ITEM 7. MATERIAL TO BE FILED AS EXHIBITS None. SIGNATURE After reasonable inquiry and to the best of my knowledge and belief, I certify that the information set forth in this statement is true, complete and correct. Date: MARCH 30, 2001 WISCONSIN UNITED FOR HEALTH FOUNDATION, INC. By: /s/ Ben Brancel ---------------------------- Ben Brancel, President COBALT CORPORATION By: /s/ Cathy Harvey ---------------------------- Cathy Harvey, Vice President BLUE CROSS & BLUE SHIELD UNITED OF WISCONSIN, INC. By: /s/ Cathy Harvey ---------------------------- Cathy Harvey, Vice President -5- -----END PRIVACY-ENHANCED MESSAGE-----