-----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, MJSmTOckUI1WMyLaD/N1+L/3Nt8Vc/OSLg7NrxmE6vhbVLlwDqZ/5IBlSytCSbRc ws5tV7pC1ccRHfW18QK8tQ== 0000898080-02-000383.txt : 20021009 0000898080-02-000383.hdr.sgml : 20021009 20021009163158 ACCESSION NUMBER: 0000898080-02-000383 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20021009 FILED AS OF DATE: 20021009 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: MONTPELIER RE HOLDINGS LTD CENTRAL INDEX KEY: 0001165880 STANDARD INDUSTRIAL CLASSIFICATION: FIRE, MARINE & CASUALTY INSURANCE [6331] IRS NUMBER: 000000000 STATE OF INCORPORATION: D0 FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-31468 FILM NUMBER: 02785262 BUSINESS ADDRESS: STREET 1: MINTFLOWER PLACE STREET 2: 8 PAR-LA-VILLE ROAD CITY: HAMILTON HM 08 STATE: B0 ZIP: 00000 BUSINESS PHONE: 441 296 5550 MAIL ADDRESS: STREET 1: MINTFLOWER PLACE STREET 2: 8 PAR-LA-VILLE ROAD CITY: HAMILTON HM 08 STATE: B0 ZIP: 00000 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: WHITE MOUNTAINS INSURANCE GROUP LTD CENTRAL INDEX KEY: 0000776867 STANDARD INDUSTRIAL CLASSIFICATION: FIRE, MARINE & CASUALTY INSURANCE [6331] RELATIONSHIP: OWNER IRS NUMBER: 942708455 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 BUSINESS ADDRESS: STREET 1: 28 GATE STREET CITY: WHITE RIVER JUNCTION STATE: VT ZIP: 05001-7066 BUSINESS PHONE: 8022954500 MAIL ADDRESS: STREET 1: 28 GATES STREET CITY: WHITE RIVER JUNCTION STATE: VT ZIP: 05001-7066 FORMER COMPANY: FORMER CONFORMED NAME: FUND AMERICAN COMPANIES INC DATE OF NAME CHANGE: 19920701 FORMER COMPANY: FORMER CONFORMED NAME: FUND AMERICAN ENTERPRISES HOLDINGS INC DATE OF NAME CHANGE: 19920703 FORMER COMPANY: FORMER CONFORMED NAME: WHITE MOUNTAINS INSURANCE GROUP INC DATE OF NAME CHANGE: 19990603 3 1 form3.txt FORM 3
FORM 3 U.S. SECURITIES AND EXCHANGE COMMISSION OMB APPROVAL Washington, D.C. 20549 OMB Number 3235-0104 Expires: January 31, 2005 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Estimated average burden hours per response ... 0.5 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(f) of the Investment Company Act of 1940 - ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting 2. Date of Event 4. Issuer Name and Ticker or Trading Person* Requiring Statement Symbol (Month/Day/Year) White Mountains Insurance Group, Ltd. October 9, 2002 Montpelier Re Holdings Ltd., "MRH" on the New York Stock Exchange - ------------------------------------------------------------------------------------------------------------------------------------ (Last) (First) (Middle) 3. I.R.S. or Social 5. Relationship of Reporting Person 6. If Amendment, Date of Security Number of to Issuer (Check all applicable) Original (Month/Day/Year) One Beacon Street Person (Voluntary) ---------------------------- - -------------------------------------- Director X Owner 7. Individual or Joint/Group (Street) --- --- Filing (Check applicable line) Boston, Massachusetts 02108 --- Officer --- Other Form filed by one - -------------------------------------- (give title below) (specify below) --- Reporting Person (City) (State) (Zip) X Form filed by more --- than one Reporting Person - ------------------------------------------------------------------------------------------------------------------------------------ Table I-- Non-Derivative Securities Beneficially Owned - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Amount of Securities 3. Ownership Form: 4. Nature of Indirect (Instr. 4) Beneficially Owned Direct (D) or Beneficial Ownership (Instr. 4) Indirect (I) (Instr. 5) (Instr. 5) - ------------------------------------------------------------------------------------------------------------------------------------ Common Shares 900,000 I By Camden Fire Insurance Company(1) - ------------------------------------------------------------------------------------------------------------------------------------ Common Shares 8,100,000 (2) By OneBeacon Insurance Company (1)(2) - ------------------------------------------------------------------------------------------------------------------------------------ Common Shares 1,800,000 I By Pennsylvania General Insurance Company(1) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ 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 5(b)(v). (Over) SEC 1473 (3-99) (1) Camden Fire Insurance Company, OneBeacon Insurance Company and Pennsylvania General Insurance Company are indirect wholly-owned subsidiaries of White Mountains Insurance Group, Ltd. (2) These shares are owned directly by OneBeacon Insurance Company, a ten percent owner of the issuer, and indirectly by White Mountains Insurance Group, Ltd. Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number
- ------------------------------------------------------------------------------------------------------------------------------------ FORM 3 (continued) Table II -- Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Derivative 2. Date Exercisable 3. Title and Amount of Securities 4. Conversion 5. Ownership 6. Nature of Security (Instr. 4) and Expiration Date Underlying Derivative Security or Exercise Form of Indirect (Month/Day/Year) (Instr. 4) Price of Derivative Beneficial Derivative Security: Ownership Security Direct (D) or (Instr. 5) --------------------------------------------------------- Indirect (I) (Instr. 5) Amount or Date Expiration Title Number of Exercisable Date Shares - ------------------------------------------------------------------------------------------------------------------------------------ Warrant Shares Currently 1/3/2012 Common Shares 4,781,571 $16.67 D Exercisable - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ Explanation of Responses: By: /s/ Dennis Beaulieu September 26, 2002 -------------------------------- ------------------ Name: Dennis Beaulieu Date Title: Corporate Secretary On behalf of White Mountains Insurance Group, Ltd. ** Signature of Reporting Person By: /s/ Dennis Beaulieu September 26, 2002 -------------------------------- ------------------ Name: Dennis Beaulieu Date Attorney-in-fact On behalf of OneBeacon Insurance Company ** Signature of Reporting Person * 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 provided is insufficient, See Instruction 6 for procedure. Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. Page 2 of 2 SEC 1473 (3-99)
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