-----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, QePbBuUOWnlYnTrzdTXK/SHLiR6fiV/ZD3JTNphRiAsv871hmuXqsDhLow70QtAJ JU0u6FyrBg5c/SuHnIga9A== 0000904454-07-000049.txt : 20070209 0000904454-07-000049.hdr.sgml : 20070209 20070209094749 ACCESSION NUMBER: 0000904454-07-000049 CONFORMED SUBMISSION TYPE: SC 13G/A PUBLIC DOCUMENT COUNT: 1 FILED AS OF DATE: 20070209 DATE AS OF CHANGE: 20070209 SUBJECT COMPANY: 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 FILING VALUES: FORM TYPE: SC 13G/A SEC ACT: 1934 Act SEC FILE NUMBER: 005-81301 FILM NUMBER: 07595692 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 FILED BY: COMPANY DATA: COMPANY CONFORMED NAME: WELSH CARSON ANDERSON & STOWE VII LP ET AL CENTRAL INDEX KEY: 0001012089 IRS NUMBER: 000000000 STATE OF INCORPORATION: DE FILING VALUES: FORM TYPE: SC 13G/A 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 SC 13G/A 1 s13ga_123106-amerisafe.txt AMD TO SCHED 13G FOR AMERISAFE BY WCAS VIII CUSIP No. 03071H 10 0 Page 1 of 5 Pages SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 ---------------------- SCHEDULE 13G (Rule 13d-102) INFORMATION TO BE INCLUDED IN STATEMENTS FILED PURSUANT TO RULES 13d-1(b),(c), AND (d) AND AMENDMENTS THERETO FILED PURSUANT TO RULE 13d-2(b) (Amendment No. 1) Amerisafe, Inc. - -------------------------------------------------------------------------------- (Name of Issuer) Common Stock, $.01 par value - -------------------------------------------------------------------------------- (Title of Class of Securities) 03071H 10 0 - -------------------------------------------------------------------------------- (CUSIP Number) December 31, 2006 - -------------------------------------------------------------------------------- Date of Event Which Requires Filing of this Statement Check the appropriate box to designate the rule pursuant to which this Schedule is Filed: [ ] Rule 13d-1(b) [ ] Rule 13d-1(c) [X] Rule 13d-1(d) CUSIP No. 03071H 10 0 Page 2 of 5 Pages - -------------------------------------------------------------------------------- 1) Name of Reporting Person Welsh, Carson, I.R.S. Identification Anderson & Stowe No. of Above Person VII, L.P. (Entities Only) - -------------------------------------------------------------------------------- 2) Check the Appropriate Box (a) [ X ] if a Member of a Group (b) [ ] - -------------------------------------------------------------------------------- 3) SEC Use Only - -------------------------------------------------------------------------------- 4) Citizenship or Place Delaware of Organization - -------------------------------------------------------------------------------- Number of 5) Sole Voting -0- Shares Beneficially Power Owned by Each Reporting Person With: ----------------------------------------------- 6) Shared Voting -0- Power ----------------------------------------------- 7) Sole Dispositive -0- Power ----------------------------------------------- 8) Shared Dis- -0- positive Power ----------------------------------------------- 9) Aggregate Amount Beneficially -0- Owned by Each Reporting Person - -------------------------------------------------------------------------------- 10) Check if the Aggregate Amount in Row (9) Excludes Certain Shares - -------------------------------------------------------------------------------- 11) Percent of Class -0- Represented by Amount in Row (9) - -------------------------------------------------------------------------------- 12) Type of Reporting PN Person CUSIP No. 03071H 10 0 Page 3 of 5 Pages - -------------------------------------------------------------------------------- 1) Name of Reporting Person WCAS Healthcare I.R.S. Identification Partners, L.P. No. of Above Person (Entities Only) - -------------------------------------------------------------------------------- 2) Check the Appropriate Box (a) [ X ] if a Member of a Group (b) [ ] - -------------------------------------------------------------------------------- 3) SEC Use Only - -------------------------------------------------------------------------------- 4) Citizenship or Place Delaware of Organization - -------------------------------------------------------------------------------- Number of 5) Sole Voting -0- Shares Beneficially Power Owned by Each Reporting Person With: ----------------------------------------------- 6) Shared Voting -0- Power ----------------------------------------------- 7) Sole Dispositive -0- Power ----------------------------------------------- 8) Shared Dis- -0- positive Power ----------------------------------------------- 9) Aggregate Amount Beneficially -0- Owned by Each Reporting Person - -------------------------------------------------------------------------------- 10) Check if the Aggregate Amount in Row (9) Excludes Certain Shares - -------------------------------------------------------------------------------- 11) Percent of Class -0- Represented by Amount in Row (9) - -------------------------------------------------------------------------------- 12) Type of Reporting PN Person CUSIP No. 03071H 10 0 Page 4 of 5 Pages Amendment No. 1 to Schedule 13G (Final Amendment) ------------------------------------------------- Reference is hereby made to the statement on Schedule 13G filed with the Securities and Exchange Commission on January 24, 2006 (the "Schedule 13G"). Terms defined in the Schedule 13G are used herein as so defined. The following items of the Schedule 13G are hereby amended and restated as follows: Item 4 - Ownership. (a) Amount Beneficially Owned: WCAS VII: -0- WCAS HP: -0- (b) Percent of Class: WCAS VII: -0- WCAS HP: -0- (c) Number of shares as to which such persons have: (i) sole power to vote or to direct the vote: -0- (ii) shared power to vote or to direct the vote: -0- (iii) sole power to dispose or to direct the disposition of: -0- (iv) shared power to dispose or to direct the disposition of: -0- Item 5 - Ownership Of Five Percent Or Less Of A Class. If this statement is being filed to report the fact that as of the date hereof the Reporting Persons have ceased to be the beneficial owners of more than five percent of the Common Stock, check the following: [X] CUSIP No. 03071H 10 0 Page 5 of 5 Pages Signature: After reasonable inquiry and to the best of their knowledge and belief, the undersigned certify that the information set forth in this statement is true, complete and correct. WELSH, CARSON, ANDERSON & STOWE VII, L.P. By: WCAS VII Partners, L.P., General Partner By /s/ Jonathan M. Rather --------------------------------------------- General Partner WCAS HEALTHCARE PARTNERS, L.P. By: WCAS HP Partners, General Partner By /s/ Jonathan M. Rather --------------------------------------------- Attorney-in-Fact Date: February 7, 2007 -----END PRIVACY-ENHANCED MESSAGE-----