-----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, Iv1bjPLqMqFdCSg2hm65sCftEyjhyDzT2s0aTKdJ6l03bw5zOnLDhGeMoYoxWfnx 8heoRz0c0H3hhMiQ2xLbGQ== 0001140361-09-024004.txt : 20091028 0001140361-09-024004.hdr.sgml : 20091028 20091028174303 ACCESSION NUMBER: 0001140361-09-024004 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20090315 FILED AS OF DATE: 20091028 DATE AS OF CHANGE: 20091028 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: AMERICAN SAFETY INSURANCE HOLDINGS LTD CENTRAL INDEX KEY: 0000783603 STANDARD INDUSTRIAL CLASSIFICATION: INSURANCE AGENTS BROKERS & SERVICES [6411] IRS NUMBER: 000000000 FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 31 QUEENS STREET STREET 2: 2ND FLOOR CITY: HAMILTON STATE: D0 ZIP: HM 11 BUSINESS PHONE: 441-296-8560 MAIL ADDRESS: STREET 1: 31 QUEENS STREET STREET 2: 2ND FLOOR CITY: HAMILTON STATE: D0 ZIP: HM 11 FORMER COMPANY: FORMER CONFORMED NAME: AMERICAN SAFETY INSURANCE GROUP LTD DATE OF NAME CHANGE: 19971218 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: William Clarence Tepe CENTRAL INDEX KEY: 0001345760 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-14795 FILM NUMBER: 091142706 BUSINESS ADDRESS: STREET 1: 1845 THE EXCHANGE CITY: ATLANTA STATE: 2Q ZIP: 30102 BUSINESS PHONE: 770-485-4373 MAIL ADDRESS: STREET 1: 1845 THE EXCHANGE CITY: ATLANTA STATE: 2Q ZIP: 30102 4 1 doc1.xml FORM 4 X0303 4 2009-03-15 0 0000783603 AMERICAN SAFETY INSURANCE HOLDINGS LTD ASI 0001345760 William Clarence Tepe 44 CHURCH STREET P.O. BOX HM 2064 HAMILTON D0 HM 11 BERMUDA 0 1 0 0 CFO Common Stock 2009-03-31 4 A 0 7322 11.51 A 14200 D Stock Option 16.18 2009-03-31 4 D 0 25000 16.18 D 2009-03-31 2009-03-31 Common Stock 25000 0 D Stock Option 19.05 2009-03-31 4 D 0 7500 19.05 D 2009-03-31 2009-03-31 Common Stock 7500 0 D Stock Option 17.95 2009-03-31 4 D 0 7500 17.95 D 2009-03-31 2009-03-31 Common Stock 7500 0 D Stock Option 17.95 2009-03-31 4 D 0 11766 17.95 D 2009-03-31 2009-03-31 Common Stock 11766 0 D Stock Option 9.10 2009-03-31 4 D 0 14589 9.10 D 2009-03-31 2009-03-31 Common Stock 14589 0 D Shares issued as part of the Company's 2008 Long-Term Incentive Plan. Scheduled vesting was accelerated to vest on 03-31-2009 as part of the 03-15-2009 Separation Agreement. Stock options forfeited as part of the 03-15-2009 Separation Agreement. /s/ William C. Tepe 2009-10-28 -----END PRIVACY-ENHANCED MESSAGE-----