0001181431-13-057709.txt : 20131107 0001181431-13-057709.hdr.sgml : 20131107 20131107180414 ACCESSION NUMBER: 0001181431-13-057709 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20131107 FILED AS OF DATE: 20131107 DATE AS OF CHANGE: 20131107 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: 131202023 MAIL ADDRESS: STREET 1: AMERISAFE INC STREET 2: 2301 HIGHWAY 190 WEST CITY: DERIDDER STATE: LA ZIP: 70634 4 1 rrd394778.xml FORM 4 X0306 4 2013-11-07 0 0001018979 AMERISAFE INC AMSF 0001341774 BANTA GEOFFREY R 2301 HIGHWAY 190 WEST DERIDDER LA 70634 0 1 0 0 EVP/Corporate Development Common Stock, par value $0.01 2013-11-07 4 M 0 3000 9 A 14490 D Common Stock, par value $0.01 2013-11-07 4 S 0 3000 39.08 D 11490 D Employee Stock Option (right to purchase) 9 2013-11-07 4 M 0 3000 0 D 2008-11-17 2015-11-17 Common Stock 3000 69250 D Represents the weighted average selling price of the Issuer's common stock. The range of the sales prices were between $39.00 and $39.04. 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/ Kathryn H. Rowan, attorney-in-fact for Geoffrey R. Banta 2013-11-07