-----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, ELc+EoOyftlrRkDovbvbtGuZXN12IOeWINqvL+prg2qYTON00uvAxrbuRfbuDhrY ZOLz8p3to+F8yiLUFzO38g== 0001209191-04-059898.txt : 20041230 0001209191-04-059898.hdr.sgml : 20041230 20041230151152 ACCESSION NUMBER: 0001209191-04-059898 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20041221 FILED AS OF DATE: 20041230 DATE AS OF CHANGE: 20041230 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: SOKOL SI CENTRAL INDEX KEY: 0000938330 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-08738 FILM NUMBER: 041233875 MAIL ADDRESS: STREET 1: 20 EAST BROAD STREET 4TH FLOOR CITY: COLUMBUS STATE: OH ZIP: 43215 FORMER NAME: FORMER CONFORMED NAME: SOKOL SI ET AL DATE OF NAME CHANGE: 19950807 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: BANCINSURANCE CORP CENTRAL INDEX KEY: 0000276400 STANDARD INDUSTRIAL CLASSIFICATION: FIRE, MARINE & CASUALTY INSURANCE [6331] IRS NUMBER: 310790882 STATE OF INCORPORATION: OH FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 250 EAST BROAD STREET STREET 2: 10TH FLOOR CITY: COLUMBUS STATE: OH ZIP: 43215 BUSINESS PHONE: 6142282800 MAIL ADDRESS: STREET 1: 250 EAST BROAD STREET STREET 2: 10TH FLOOR CITY: COLUMBUS STATE: OH ZIP: 43215 4 1 doc4.xml FORM 4 SUBMISSION X0202 4 2004-12-21 0 0000276400 BANCINSURANCE CORP BCIS 0000938330 SOKOL SI 250 E. BROAD ST. 10TH FLOOR COLUMBUS OH 43215 1 1 1 0 Chairman and CEO Common Shares 2004-12-21 5 G 0 E 4500 0.00 D 314476 D Simon Sokol also indirectly owns 310,492 BCIS common shares which are owned by Simon Sokol's wife, Barbara K. Sokol. Simon Sokol disclaims beneficial ownership of such BCIS common shares, and the filing of this report is not an admission that Simon Sokol is the beneficial owner of such BCIS common shares for purposes of Section 16 or for any other purpose. Simon Sokol may also be deemed to indirectly own 1,750,000 BCIS common shares which are owned by Falcon Equity Partners, L.P. ("Falcon L.P."), an Ohio limited partnership whose partners are members of the Simon Sokol family. Simon Sokol holds a 35.7 percentage interest in Falcon L.P., and disclaims beneficial ownership of BCIS common shares held by Falcon L.P., except to the extent of his individual pecuniary interest therein. /s/Matthew C. Nolan, As Attorney in Fact 2004-12-30 -----END PRIVACY-ENHANCED MESSAGE-----