-----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, IlaO7m01/hWhkcY/HHCwZFi2SGOf0E1josRkMUKxHvz78kPNHZXuMKQfFAQmueRg mE3uzte3+rXFi5WYGDKCig== 0000950134-96-005140.txt : 19961001 0000950134-96-005140.hdr.sgml : 19961001 ACCESSION NUMBER: 0000950134-96-005140 CONFORMED SUBMISSION TYPE: 8-A12B PUBLIC DOCUMENT COUNT: 1 FILED AS OF DATE: 19960930 SROS: NONE FILER: 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: 8-A12B SEC ACT: 1934 Act SEC FILE NUMBER: 001-12251 FILM NUMBER: 96637331 BUSINESS ADDRESS: STREET 1: 5550 LBJ FREEWAY STREET 2: STE 901 CITY: DALLAS STATE: TX ZIP: 75240 BUSINESS PHONE: 2144487414 MAIL ADDRESS: STREET 1: 5550 LBJ FREEWAY STREET 2: STE 901 CITY: DALLAS STATE: TX ZIP: 75240 8-A12B 1 FORM 8-A 1 ================================================================================ SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 ----------------------------------- FORM 8-A FOR REGISTRATION OF CERTAIN CLASSES OF SECURITIES PURSUANT TO SECTION 12(b) or (g) OF THE SECURITIES EXCHANGE ACT OF 1934 AMERISAFE, INC. (Exact name of Registrant as specified in its charter) TEXAS 75-2069407 (State of incorporation (I.R.S. Employer or organization) Identification No.) 2301 HIGHWAY 190 WEST, DERIDDER, LOUISIANA 70634 (Address of principal executive offices) (Zip Code) If this form relates to the If this form relates to the registration of a class of debt registration of a class of debt securities and is effective upon securities and is to become effective filing pursuant to General Instruction simultaneously with the effectiveness A(c)(1) please check the following of a concurrent registration statement box. [ ] under the Securities Act of 1933 pursuant to General Instruction A(c)(2) please check the following box. [ ] SECURITIES TO BE REGISTERED PURSUANT TO SECTION 12(B) OF THE ACT: TITLE OF EACH CLASS NAME OF EACH EXCHANGE ON WHICH TO BE SO REGISTERED EACH CLASS IS TO BE REGISTERED ------------------- ------------------------------ Class A Common Stock, New York Stock Exchange par value $.01 per share SECURITIES TO BE REGISTERED PURSUANT TO SECTION 12(G) OF THE ACT: Not applicable ================================================================================ Page 1 of 3 Pages 2 ITEM 1. DESCRIPTION OF REGISTRANT'S SECURITIES TO BE REGISTERED. The description of the Class A Common Stock, $.01 par value per share (the "Common Stock"), of AMERISAFE, Inc. (the "Company") set forth under the caption "Description of Capital Stock" in Amendment No. 1 to the Registration Statement on Form S-1 (Commission File No. 333-10099), filed by the Company with the Securities and Exchange Commission on September 25, 1996, including exhibits, is hereby incorporated by reference. ITEM 2. EXHIBITS. All exhibits required by Instruction II to Item 2 will be filed with the New York Stock Exchange. Page 2 of 3 Pages 3 SIGNATURE Pursuant to the requirements of Section 12 of the Securities Exchange Act of 1934, the registrant has duly caused this registration statement to be signed on its behalf by the undersigned, thereunto duly authorized. AMERISAFE, INC. Date: September 27, 1996 By: /s/ ARTHUR L. HUNT ------------------------------- Arthur L. Hunt Vice President Page 3 of 3 Pages -----END PRIVACY-ENHANCED MESSAGE-----