-----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, ML/yY/uWnXjqryYnJ9vldKebrScKhzek+e3N3yu7HqEnIQ7p0DTPvIaCopY8AFiK eHfTBkKglSr+JD1gWC5yTg== 0001013698-01-000001.txt : 20010123 0001013698-01-000001.hdr.sgml : 20010123 ACCESSION NUMBER: 0001013698-01-000001 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20001231 FILED AS OF DATE: 20010111 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: SYMONS INTERNATIONAL GROUP INC CENTRAL INDEX KEY: 0001013698 STANDARD INDUSTRIAL CLASSIFICATION: FIRE, MARINE & CASUALTY INSURANCE [6331] IRS NUMBER: 351707115 STATE OF INCORPORATION: IN FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: SEC FILE NUMBER: 000-29042 FILM NUMBER: 1507094 BUSINESS ADDRESS: STREET 1: 4720 KINGSWAY DRIVE CITY: INDIANAPOLIS STATE: IN ZIP: 46205 BUSINESS PHONE: 3172596400 MAIL ADDRESS: STREET 1: 4720 KINGSWAY DRIVE CITY: INDIANAPOLIS STATE: IN ZIP: 46205 COMPANY DATA: COMPANY CONFORMED NAME: SYMONS DOUGLAS H CENTRAL INDEX KEY: 0001072614 STANDARD INDUSTRIAL CLASSIFICATION: [] OWNER FILING VALUES: FORM TYPE: 4 BUSINESS ADDRESS: STREET 1: 4720 KINGSWAY DR CITY: INDIANAPOLIS STATE: IN ZIP: 46205 BUSINESS PHONE: 3172596360 MAIL ADDRESS: STREET 1: 7436 GLENVISTA PLACE CITY: FISHERS STATE: IN ZIP: 46038 4 1 0001.txt STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 4 SYMONS INTERNATIONAL GROUP, INC. STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP: ( ) Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instructions 1 (b). 1. Name and Address of Reporting Symons, Douglas H. 7436 Glenvista Place Fishers, Indiana 46038 USA 2. Issuer Name and Ticker or Trading Symbol Symons International Group, Inc. SIGC 3. IRS or Social Security Number of Reporting Person (Voluntary) ###-##-#### 4. Statement for Month/Year 12/00 5. If Amendment, Date of Original (Month/Year) 6. Relationship of Reporting Person (s) to Issuer (Check all applicable) (X) Director ( ) 10% Owner (X) Officer (give title below) ( ) Other (Specify Below) Chief Executive Officer 7. Individual or Joint/Group Filing (Check Applicable Line) (X) Form filed by One Reporting Person ( ) Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned 1. Title of 2. 4. Securities acquired (A) or 5. Amount of Securities 6. Direct 7. Nature of Security 3. Disposed of (D) Benefically Owned at End of (D) or Indirect Transactions Month Indirect (I) Beneficial Ownership Date Code V Amount A/D Price Common 11/15/00 P 500 A .4375 D 35,500 Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned 1. Title of Derivative 2. Conversion of Exercise 3. 5. Number of 6. Date Exercisable Security Price of Derivative Security 4. Derivative and Expiration Date Transaction Securities (Month/Day/Year) Acquired (A) or Disposed (D) Date Code V Amount A/D Date Expiration Exercisable Date 7. Title and Amount 8. Price of Derivative Security 9. Number of Derivative Securities of Underlying Benefically Owned at End of Month Securities Title and Number of Shares
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