4/A 1 l96610ae4za.htm BANCINSURANCE CORPORATION/DANIEL D. HARKINS FORM 4 Bancinsurance Corporation/Daniel D. Harkins Form 4
 

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UNITED STATES
SECURITIES AND EXCHANGE COMMISSION

Washington, DC 20549

FORM 4

STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934,
Section 17(a) of the Public Utility Holding Company Act of 1935
or Section 30(h) of the Investment Company Act of 1940

o Check this box if no longer
subject to Section 16.
Form 4 or Form 5
obligations may continue.
See Instruction 1(b).

1. Name and Address of Reporting
Person*
(Last, First, Middle)
2. Issuer Name and Ticker or
Trading Symbol
3. I.R.S. Identification Number of Reporting
Person, if an entity
(Voluntary)
  Harkins, Daniel D
  Bancinsurance Corporation BCIS
 
 
250 East Broad Street 10th Floor

4. Statement for Month/Day/Year 5. If Amendment, Date of Original (Month/Day/Year)
    June 4, 2002
  July 1, 2002
  (Street) 6. Relationship of Reporting Person(s)
to Issuer
(Check All Applicable)
7. Individual or Joint/Group Filing
(Check Applicable Line)
  Columbus, OH 43215
(City)                (State)           (Zip)
  x  Director o  10% Owner   x Form filed by One Reporting Person
    o  Officer (give title below)   o Form filed by More than One Reporting Person
    o  Other (specify below)  
       
     

Reminder:   Report on a separate line for each class of securities beneficially owned directly or indirectly.
 
*   If the form is filed by more than one reporting person, see instruction 4(b)(v).
 

 


 


Table I — Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned

1. Title of Security
(Instr. 3)
2. Transaction Date
(Month/Day/Year)
2a. Deemed Execution
Date, if any.

(Month/Day/Year)
3. Transaction Code
(Instr. 8)
4. Securities Acquired (A)
or Disposed of (D)

(Instr. 3, 4 and 5)
5. Amount of Securities
Beneficially Owned
Following Reported
Transactions(s)

(Instr. 3 and 4)
6. Ownership
Form:
Direct (D) or
Indirect (I)

(Instr. 4)
7. Nature of
Indirect
Beneficial
Ownership

(Instr. 4)

              Code V   Amount (A)
or
(D)
Price            

                   

                     

                     

                     

                     

                     

                     

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Table II — Derivative Securities Acquired, Disposed of, or Beneficially Owned
  (e.g., puts, calls, warrants, options, convertible securities)

1. Title of Derivative
Security

(Instr. 3)
2. Conversion or Exercise
Price of Derivative
Security
3. Transaction
Date

(Month/Day/Year)
3a. Deemed Execution
Date, if any

(Month/Day/Year)
4. Transaction
Code

(Instr. 8)
5. Number of Derivative Securities
Acquired (A) or Disposed of (D)

(Instr. 3, 4 and 5)

                      Code V   (A) (D)

  Option to purchase Common Shares   5.30     6/4/02     A V   2,000

             

             

             

             

             

             

             

             

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Table II — Derivative Securities Acquired, Disposed of, or Beneficially Owned — Continued
(e.g., puts, calls, warrants, options, convertible securities)

6. Date Exercisable and
Expiration Date

(Month/Day/Year)
7. Title and Amount
of Underlying Securities

(Instr. 3 and 4)
8. Price of Derivative
Security

(Instr. 5)
9. Number of Derivative
Securities Beneficially Owned
Following Reported Transaction(s)

(Instr. 4)
10. Ownership Form of
Derivative Security:
Direct (D) or Indirect (I)

(Instr. 4)
11. Nature of
Indirect
Beneficial
Ownership

(Instr. 4)

  Date
Exercisable
Expiration
Date
  Title Amount or
Number of
Shares
                       

  6/4/03 6/3/12   Common Shares 2,000         2,000     D  

                 

                 

                 

                 

                 

                 

                 

                 

Explanation of Responses:

Daniel D. Harkins
/s/ Sally J. Cress as Attorney-in-Fact
  October 9, 2002

**Signature of Reporting Person
 
Date


**   Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
 
Note:   File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.
 

Page 4


 

APPENDIX C

POWER OF ATTORNEY

     KNOW ALL MEN BY THESE PRESENTS: That the undersigned officer and/or director of Bancinsurance Corporation (the “Company”), hereby constitutes and appoints John S. Sokol and Sally J. Cress, and each of them, as his or her true and lawful attorneys-in-fact and agents, with full power of substitution and resubstitution, for him or her and in his or her name, place and stead, in any and all capacities, to sign any and all Forms 3, 4 and 5 that are required by Section 16(a) of the Securities Exchange Act of 1934, as amended, with respect to the securities of the Company beneficially owned by the undersigned, and any and all amendments thereto, and to file the same, and other documents relating thereto, with the Securities and Exchange Commission and any other applicable authority, and grants unto each of said attorneys-in-fact and substitute or substitutes full power and authority to do each and every act and thing requisite and necessary to be done in and about the premises, as fully to all intents and purposes as he or she might do in person, and hereby ratifies and confirms all things that each of said attorneys-in-fact and substitute or substitutes may lawfully do and seek to be done by virtue hereof.

     This Power of Attorney shall be valid until such time as it is revoked by the undersigned in writing.

     IN WITNESS WHEREOF, the undersigned has hereunto set his or her hand this 24th day of April, 1991.

     
  /s/ Daniel D. Harkins

Daniel D. Harkins