-----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, KN6qHy7cZJMmkFDgU8DpB7Ej48K0ZfSghb645WFwwoT1bYC8dEHM1V2ntju9/9rf 68C0tEMNAXprA/PlZPcEzw== 0000904454-06-000045.txt : 20060125 0000904454-06-000045.hdr.sgml : 20060125 20060125113939 ACCESSION NUMBER: 0000904454-06-000045 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20051231 FILED AS OF DATE: 20060125 DATE AS OF CHANGE: 20060125 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: MINICUCCI ROBERT A CENTRAL INDEX KEY: 0001212991 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 001-12251 FILM NUMBER: 06548563 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 5 1 edgar.xml PRIMARY DOCUMENT X0202 5 2005-12-31 0 1 0001018979 AMERISAFE INC AMSF 0001212991 MINICUCCI ROBERT A C/O WELSH, CARSON, ANDERSON & STOWE 320 PARK AVENUE, SUITE 2500 NEW YORK NY 10022 0 0 1 0 Common Stock 2005-12-14 4 S 0 L 432231 8.37 D 7636475 I By Welsh, Carson, Anderson & Stowe VII, L.P. The Reporting Person is one of several general partners of the sole general partner of Welsh, Carson, Anderson & Stowe VII, L.P. Pursuant to Instruction 4(b)(iv) of Form 5, the Reporting Person has elected to report as indirectly beneficially owned the entire number of securities beneficially owned by such entity. The Reporting Person disclaims beneficial ownership of any securities, and any proceeds thereof, that exceed his pecuniary interest therein, and/or that are not actually distributed to him. The Reporting Person also directly beneficially owns 4,836 shares of Common Stock. /s/ Jonathan M. Rather, Attorney-in-Fact 2006-01-24 -----END PRIVACY-ENHANCED MESSAGE-----