0001209191-16-119675.txt : 20160512 0001209191-16-119675.hdr.sgml : 20160512 20160512182204 ACCESSION NUMBER: 0001209191-16-119675 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20160510 FILED AS OF DATE: 20160512 DATE AS OF CHANGE: 20160512 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: 161645292 MAIL ADDRESS: STREET 1: 2301 HIGHWAY 190 WEST CITY: DERIDDER STATE: LA ZIP: 70634 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2016-05-10 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 2016-05-10 4 M 0 1092 14.20 A 24597 D Common stock, par value $0.01 2016-05-10 4 S 0 1092 57.06 D 23505 D Common stock, par value $0.01 2016-05-11 4 M 0 2108 14.20 A 25613 D Common stock, par value $0.01 2016-05-11 4 S 0 2108 57.17 D 23505 D Employee Stock Option (right to purchase) 14.20 2016-05-10 4 M 0 600 0.00 D 2012-11-09 2019-11-09 Common stock 600 7600 D Employee Stock Option (right to purchase) 14.20 2016-05-10 4 M 0 492 0.00 D 2013-11-09 2019-11-09 Common stock 492 7108 D Employee Stock Option (right to purchase) 14.20 2016-05-10 4 M 0 2108 0.00 D 2013-11-09 2019-11-09 Common stock 2108 5000 D Represents the weighted average selling price of the Issuer's common stock. The range of sales prices were between $57.00 and $57.20. 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 the weighted average selling price of the Issuer's common stock. The range of sales prices were between $57.00 and $57.24. 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. /s/ Vincent J. Gagliano 2016-05-12