0001181431-13-016619.txt : 20130313 0001181431-13-016619.hdr.sgml : 20130313 20130313154625 ACCESSION NUMBER: 0001181431-13-016619 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20130313 FILED AS OF DATE: 20130313 DATE AS OF CHANGE: 20130313 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: BANTA GEOFFREY R CENTRAL INDEX KEY: 0001341774 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-12251 FILM NUMBER: 13687431 MAIL ADDRESS: STREET 1: AMERISAFE INC STREET 2: 2301 HIGHWAY 190 WEST CITY: DERIDDER STATE: LA ZIP: 70634 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 rrd374060.xml FORM X0306 4 2013-03-13 0 0001018979 AMERISAFE INC AMSF 0001341774 BANTA GEOFFREY R 2301 HIGHWAY 190 WEST DERIDDER LA 70634 0 1 0 0 President and COO Common Stock, par value $0.01 2013-03-13 4 M 0 6000 9 A 11500 D Common Stock, par value $0.01 2013-03-13 4 S 0 3010 33.56 D 8490 D Employee Stock Option (right to buy) 9 2013-03-13 4 M 0 6000 0 D 2008-11-17 2015-11-17 Stock, par value $0.01 6000 91750 D Represents the weighted average selling price of the Issuer's common stock. The range of the sales prices were between $33.50 and $33.65. The Reporting Person undertakes, upon request, to provide the SEC, the Issuer and any security holder of the Issuer full information regarding the number of shares sold at each separate price. /s/ Geoffrey R. Banta 2013-03-13