-----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, GT9bv7iaMnxEb65t+Iu0Z1n2ZKhePX91sSnT4QmLzVWr1NC7WVgLVjr2J3L8zCsM IzWuzAsXvJdDTHYycTxEjA== 0001209191-05-059369.txt : 20051123 0001209191-05-059369.hdr.sgml : 20051123 20051123105745 ACCESSION NUMBER: 0001209191-05-059369 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20051123 FILED AS OF DATE: 20051123 DATE AS OF CHANGE: 20051123 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: 051223345 BUSINESS ADDRESS: BUSINESS PHONE: 337-463-9052 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 doc4.xml FORM 4 SUBMISSION X0202 4 2005-11-23 0 0001018979 AMERISAFE INC AMSF 0001341774 BANTA GEOFFREY R 2301 HIGHWAY 190 WEST DERIDDER LA 70634 0 1 0 0 Executive Vice President & CFO Employee Stock Option (right to buy) 9.00 2005-11-23 4 A 0 237500 0.00 A 2015-11-17 Common Stock, par value $.01 per share 237500 237500 D The option vests in five equal installments on November 17, 2006, 2007, 2008, 2009 and 2010. /s/ Larry D. Cannon Larry D. Cannon, Attorney-in-Fact for Geoffrey R. Banta, Executive Vice President and Chief Financial Officer 2005-11-23 -----END PRIVACY-ENHANCED MESSAGE-----