-----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, Hg5pXL0VYJEZ5XyYqi1UEQ6LF894T+HQlUKb+O21JRYzERFzl1kk3/mzT/Zbtnva xvdeHgrBL180zX5OlOgz3Q== 0000950103-05-000123.txt : 20050126 0000950103-05-000123.hdr.sgml : 20050126 20050126150824 ACCESSION NUMBER: 0000950103-05-000123 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20050126 FILED AS OF DATE: 20050126 DATE AS OF CHANGE: 20050126 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: ASSURANT INC CENTRAL INDEX KEY: 0001267238 STANDARD INDUSTRIAL CLASSIFICATION: ACCIDENT & HEALTH INSURANCE [6321] IRS NUMBER: 391126612 MAIL ADDRESS: STREET 1: ONE CHASE MANHATTAN PLAZA CITY: NEW YORK STATE: NY ZIP: 10005 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: FORTIS INSURANCE N.V. CENTRAL INDEX KEY: 0001114179 STATE OF INCORPORATION: MN FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-31978 FILM NUMBER: 05549869 BUSINESS ADDRESS: STREET 1: 500 BIELENBERG DR CITY: WOODBURY STATE: MN ZIP: 55125 BUSINESS PHONE: 6517384000 MAIL ADDRESS: STREET 1: ARCHIMEDESLAAN 6 CITY: UTRECHT STATE: P7 ZIP: NL-3584 BA FORMER NAME: FORMER CONFORMED NAME: FORTIS INSURANCE N V DATE OF NAME CHANGE: 20000510 4 1 jan2505_form4ex.xml X0202 4 2005-01-26 0 0001267238 ASSURANT INC AIZ 0001114179 FORTIS INSURANCE N.V. ARCHIMEDESLAAN 6 3584 BA UTRECHT P7 NETHERLANDS 0 0 1 0 Common Stock 2005-01-26 4 S 0 27200000 30.60 D 22999130 D 7.75% Bonds due 2008 2005-01-26 4 J 0 774149000 1000 D Assurant Common Stock 774149000 D Unless exchanged early or accelerated, each bond in the principal amount of $1,000 will obligate Fortis Insurance N.V. to deliver on January 26, 2008, referred to as the maturity date, the following number of shares of Assurant, Inc. ("Assurant") common stock, subject to anti-dilution adjustments: if the average of the volume weighted average price of Assurant common stock over the 20-trading day period ending on the third trading day prior to the maturity date equals or exceeds the threshold appreciation price of $41.0652, 24.3515; if the average of the volume weighted average price of Assurant common stock over the same period is less than the threshold appreciation price of $41.0652 but is greater than the adjusted initial price of $33.6600, between 24.3515 and 29.7089; and if the average of the volume weighted average price of Assurant common stock over the same period is less than or equal to the adjusted initial price, 29.7089. US$774,149,000 7.75% bonds issued by Fortis Insurance N.V. that are mandatorily exchangeable for a number of shares of common stock of Assurant, Inc. based on the exchange ratio described above, or the cash value thereof. The bonds will be exchanged on January 26, 2008, unless exchanged early following a cash merger of Assurant, Inc. or upon certain tax events or unless the exchange is accelerated pursuant to the terms of the bonds. The bonds are mandatorily exchangeable for a maximum number of 22,999,116 shares of common stock of Assurant, Inc. See footnote 1 for an explanation of the actual number of shares of Assurant common stock that a holder of bonds will receive on the maturity date. Jean Dessain, Attorney-in-Fact, on behalf of Fortis Insurance N.V. 2005-01-26 Paul Goris, Attorney-in-Fact, on behalf of Fortis Insurance N.V. 2005-01-26 -----END PRIVACY-ENHANCED MESSAGE-----