0001209191-16-109831.txt : 20160321 0001209191-16-109831.hdr.sgml : 20160321 20160321183646 ACCESSION NUMBER: 0001209191-16-109831 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20160318 FILED AS OF DATE: 20160321 DATE AS OF CHANGE: 20160321 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: Gagliano Vincent J. CENTRAL INDEX KEY: 0001570960 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-12251 FILM NUMBER: 161519628 MAIL ADDRESS: STREET 1: 2301 HIGHWAY 190 WEST CITY: DERIDDER STATE: LA ZIP: 70634 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2016-03-18 0 0001018979 AMERISAFE INC AMSF 0001570960 Gagliano Vincent J. 2301 HIGHWAY 190 WEST DERIDDER LA 70634 0 1 0 0 EVP - Chief Risk Officer Common stock, par value $0.01 2016-03-18 4 M 0 3200 14.20 A 26705 D Common stock, par value $0.01 2016-03-18 4 S 0 3200 52.05 D 23505 D Employee STock Option (right to purchase) 14.20 2016-03-18 4 M 0 3200 0.00 D 2014-11-09 2019-11-09 Common Stock 3200 8200 D Represents the weighted average selling price of the Issuer's common stock. The range of sales prices were between $52.00 and $52.06. 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. Represents stock options that become exercisable in five equal installments beginning on November 9, 2010, which was the first anniversary of the grant date. The options were exercised and sold pursuant to the Reporting Person's 10b5-1 plan to cover taxes. /s/ Vincent J. Gagliano 2016-03-21