0001209191-17-034544.txt : 20170523 0001209191-17-034544.hdr.sgml : 20170523 20170523072809 ACCESSION NUMBER: 0001209191-17-034544 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20170519 FILED AS OF DATE: 20170523 DATE AS OF CHANGE: 20170523 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: 17862665 MAIL ADDRESS: STREET 1: 2301 HIGHWAY 190 WEST CITY: DERIDDER STATE: LA ZIP: 70634 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2017-05-19 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 2017-05-19 4 A 0 503 0.00 A 21662 D Shares issued for the 2014-2016 performance period under an award agreement between the reporting person and the Company pursuant to the Company's Equity and Incentive Compensation Plan. The awards were determined by the Compensation Committee of the Board of Directors of the Company on May 19, 2017 in accordance with the terms of the Plan and the related award agreement. /s/Kathryn H. Shirley, attorney-in-fact for Vincent J. Gagliano 2017-05-23