-----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, IgVys7BaY7cnkt9dTqrspha4QZD9Zf8IMQKzO/Oldw3UFNSTG6Si9/4XpOmCxFsI TvEqQGgOt7cDNRz+wTWCDQ== 0000904454-05-000467.txt : 20051123 0000904454-05-000467.hdr.sgml : 20051123 20051123154416 ACCESSION NUMBER: 0000904454-05-000467 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: CARSON RUSSELL L CENTRAL INDEX KEY: 0001212986 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-12251 FILM NUMBER: 051224897 BUSINESS ADDRESS: BUSINESS PHONE: 2128939500 MAIL ADDRESS: STREET 1: 320 PARK AVENUE STE 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 0001212986 CARSON RUSSELL L C/O WELSH, CARSON, ANDERSON AND 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 I By Welsh, Carson, Anderson & Stowe VII, L.P. Series A Preferred Stock 2005-11-23 4 J 0 6009 D 0 I By WCAS Healthcare Partners, L.P. Series A Preferred Stock 2005-11-23 4 J 0 6009 D 0 D Common Stock 2005-11-23 4 J 0 7867975 A 8068706 I By Welsh, Carson, Anderson & Stowe VII, L.P. Common Stock 2005-11-23 4 J 0 62902 A 64506 I By WCAS Healthcare Partners, L.P. Common Stock 2005-11-23 4 J 0 62902 A 64506 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. The Reporting Person is a general partner of the sole general partner of Welsh, Carson, Anderson & Stowe VII, L.P., and a general partner of WCAS Healthcare Partners, L.P. Pursuant to Instruction 4(b)(iv) of Form 4, the Reporting Person has elected to report as indirectly beneficially owned the entire number of securities beneficiailly owned by each such entity. The Reporting Person disclaims beneficial ownership of any securities, and any proceeds thereof, that exceed his pecunciary interest therein, and/or that are not actually distributed to him. Jonathan M. Rather, Attorney-in-Fact 2005-11-23 -----END PRIVACY-ENHANCED MESSAGE-----