0001209191-17-039600.txt : 20170613 0001209191-17-039600.hdr.sgml : 20170613 20170613173222 ACCESSION NUMBER: 0001209191-17-039600 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20170609 FILED AS OF DATE: 20170613 DATE AS OF CHANGE: 20170613 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: Roach Randy CENTRAL INDEX KEY: 0001391169 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-12251 FILM NUMBER: 17909763 MAIL ADDRESS: STREET 1: 2301 HIGHWAY 190 WEST CITY: DERIDDER STATE: LA ZIP: 70634-6006 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2017-06-09 0 0001018979 AMERISAFE INC AMSF 0001391169 Roach Randy 2301 HIGHWAY 190 WEST DERIDDER LA 70634 1 0 0 0 Common stock, par value $0.01 2017-06-09 4 A 0 922 0.00 A 8899 D Subject to restrictions that will lapse at the time of the Issuer's 2018 annual meeting of shareholders. /s/Kathryn H. Shirley, attorney-in-fact for Randall Roach 2017-06-13