-----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, G9RmJlq3Jq0RbP9enbBPeNVZ23iPbse/Yyutq7KqB+Ru5tAnFS/x7+5rRCPB1IuV vsUFFA1DpvnR9Wv2B4KBDA== 0000904454-05-000461.txt : 20051123 0000904454-05-000461.hdr.sgml : 20051123 20051123153047 ACCESSION NUMBER: 0000904454-05-000461 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20051123 FILED AS OF DATE: 20051123 DATE AS OF CHANGE: 20051123 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: WELSH CARSON ANDERSON & STOWE VII LP ET AL CENTRAL INDEX KEY: 0001012089 STATE OF INCORPORATION: DE FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-12251 FILM NUMBER: 051224805 BUSINESS ADDRESS: STREET 1: 320 PARK AVENUE STREET 2: SUITE 2500 CITY: NEW YORK STATE: NY ZIP: 10022 MAIL ADDRESS: STREET 1: 320 PARK AVENUE STREET 2: SUITE 2500 CITY: NEW YORK STATE: NY ZIP: 10022 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: AMERISAFE INC CENTRAL INDEX KEY: 0001018979 STANDARD INDUSTRIAL CLASSIFICATION: FIRE, MARINE & CASUALTY INSURANCE [6331] IRS NUMBER: 752069407 STATE OF INCORPORATION: TX FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 2301 HIGHWAY 190 WEST CITY: DERIDDER STATE: LA ZIP: 70634 BUSINESS PHONE: 337-463-9052 MAIL ADDRESS: STREET 1: 2301 HIGHWAY 190 WEST CITY: DERIDDER STATE: LA ZIP: 70634 4 1 edgar.xml PRIMARY DOCUMENT X0202 4 2005-11-23 0001018979 AMERISAFE INC AMSF 0001012089 WELSH CARSON ANDERSON & STOWE VII LP ET AL C/O WELSH, CARSON, ANDERSON & STOWE 320 PARK AVENUE, SUITE 2500 NEW YORK NY 10022 0 0 1 0 Series A Preferred Stock 2005-11-23 4 J 0 751602 D 0 D Common Stock 2005-11-23 4 J 0 7867975 A 8068706 D Upon the closing of the Issuer's initial public offering, a portion of the Series A Preferred Stock was redeemed for cash (at a price of $101.03 per share) and the remainder was exchanged for Common Stock at a rate based on an initial public offering price of $9.00 per share of Common Stock. Includes shares issued as dividends accrued through 11/23/05. Jonathan M. Rather, General Partner of WCAS VII Partners, L.P., General Partner of Welsh, Carson, Anderson & Stowe VII, L.P. 2005-11-23 -----END PRIVACY-ENHANCED MESSAGE-----