0001181431-13-044209.txt : 20130812 0001181431-13-044209.hdr.sgml : 20130812 20130812184347 ACCESSION NUMBER: 0001181431-13-044209 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20130809 FILED AS OF DATE: 20130812 DATE AS OF CHANGE: 20130812 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 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: 131030927 MAIL ADDRESS: STREET 1: AMERISAFE INC STREET 2: 2301 HIGHWAY 190 WEST CITY: DERIDDER STATE: LA ZIP: 70634 4 1 rrd388069.xml FORM 4 X0306 4 2013-08-09 0 0001018979 AMERISAFE INC AMSF 0001341774 BANTA GEOFFREY R 2301 HIGHWAY 190 WEST DERIDDER LA 70634 0 1 0 0 President Common Stock, par value $0.01 2013-08-09 4 M 0 3668 9 A 15158 D Common Stock, par value $0.01 2013-08-09 4 S 0 3668 33.38 D 11490 D Employee Stock Option (right to buy) 9 2013-08-09 4 M 0 3668 0 D 2008-11-17 2015-11-17 Stock, par value $0.01 3668 78250 D Represents the weighted average selling price of the Issuer's common stock. The range of the sales prices were between $33.33 and $33.42. The Reporting Person undertakes, upon request, to provide the SEC, the Issuer and any security holder of the Issuer full informatoin regarding the number of shares sold at each separate price. /s/ Kathryn H. Rowan, attorney-in-fact for Geoffrey R. Banta 2013-08-12