-----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, OC2C2r4zAmMVzqJ+al3aPpaXT3jixMJ0o4MCxwNL+KIrag8vWCOlXe4GBwIQvgor XXyQINZEd2k1RmSSUzw0+g== 0000008177-03-000022.txt : 20030205 0000008177-03-000022.hdr.sgml : 20030205 20030205110443 ACCESSION NUMBER: 0000008177-03-000022 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20030130 FILED AS OF DATE: 20030205 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: ATLANTIC AMERICAN CORP CENTRAL INDEX KEY: 0000008177 STANDARD INDUSTRIAL CLASSIFICATION: LIFE INSURANCE [6311] IRS NUMBER: 581027114 STATE OF INCORPORATION: GA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-03722 FILM NUMBER: 03539776 BUSINESS ADDRESS: STREET 1: 4370 PEACHTREE RD NE CITY: ATLANTA STATE: GA ZIP: 30319 BUSINESS PHONE: 4042665500 MAIL ADDRESS: STREET 1: 4370 PEACHTREE ROAD CITY: ATLANTA STATE: GA ZIP: 30319 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: ROBINSON J MACK CENTRAL INDEX KEY: 0001008889 RELATIONSHIP: DIRECTOR FILING VALUES: FORM TYPE: 4 BUSINESS ADDRESS: STREET 1: 4370 PEACHTREE RD CITY: ATLANTA STATE: GA ZIP: 30319 BUSINESS PHONE: 4042312111 MAIL ADDRESS: STREET 1: 4370 PEACHTREE RD CITY: ATLANTA STATE: GA ZIP: 30319 4 1 form4_020503.txt STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP ------------------------------ OMB APPROVAL ------------------------------ OMB Number Expires: Estimated average burden hours per response ....... 0.5 ------------------------------ U.S. SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 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(f) of the Investment Company Act of 1940 [ ] Check this box if no longer subject of Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). ================================================================================ 1. Name and Address of Reporting Person* Robinson J. Mack - -------------------------------------------------------------------------------- (Last) (First) (Middle) 4370 Peachtree Road, NE - -------------------------------------------------------------------------------- (Street) Atlanta GA 30319-3000 - -------------------------------------------------------------------------------- (City) (State) (Zip) ================================================================================ 2. Issuer Name and Ticker or Trading Symbol Atlantic American Corporation - AAME ================================================================================ 3. IRS or Social Security Number of Reporting Person (Voluntary) ================================================================================ 4. Statement for Month/Year January 30, 2003 ================================================================================ 5. If Amendment, Date of Original (Month/Year) ================================================================================ 6. Relationship of Reporting Person to Issuer (Check all applicable) [ X ] Director [ X ] 10% Owner [ X ] Officer (give title below) [ ] Other (specify below) Chairman ================================================================================ 7. Individual or Joint/Group Filing (Check applicable line) [ X ] Form filed by one Reporting Person [ ] Form filed by more than one Reporting Person ================================================================================ Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned ================================================================================
6. 4. 5. Owner- Securities Acquired (A) or Amount of ship 3. Disposed of (D) Securities Form: 7. Transaction (Instr. 3, 4 and 5) Beneficially Direct Nature of 2. Code ------------------------------- Owned at End (D) or Indirect 1. Transaction (Instr. 8) (A) of Month Indirect Beneficial Title of Security Date ------------ Amount or Price (Instr. 3 (I) Ownership (Instr. 3) (mm/dd/yy) Code V (D) and 4) (Instr.4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 8,929 D 401(k) Plan(1) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock N/A 740,921 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock N/A 294,000 I By Delta Fire & Casualty - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock N/A 936,702 I By Delta Life Ins. Co. - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 01/30/03 P 700 A $1.65 I - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 02/03/03 P 1,000 A $1.499 8,413,780 I By Spouse 2(***) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock N/A 3,411,102 I Capital Services (3) - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
* If the Form is filed by more than one Reporting Person, see Instruction 4(b)(v). Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. Page 1 of 2 FORM 4 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================
9. 10. Number Owner- of ship 2. Deriv- of Conver- 5. 7. ative Deriv- 11. sion Number of Title and Amount Secur- ative Nature of Derivative 6. of Underlying 8. ities Secur- of Exer- 4. Securities Date Securities Price Bene- ity: In- cise 3. Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct Price Trans- action or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene- 1. of action Code of(D) (Month/Day/Year) Amount ative at End In- ficial Title of Deriv- Date (Instr. (Instr. 3, ---------------- or Secur- of direct Owner- Derivative ative (Month/ 8) 4 and 5) Date Expira- Number ity Month (I) ship Security Secur- Day/ ------ ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity Year) Code V (A) (D) cisable Date Title Shares 5) 4) 4) 4) - ------------------------------------------------------------------------------------------------------------------------------------ Employee Stock N/A Cmn. Stk. 100,000 D 4 Option - ------------------------------------------------------------------------------------------------------------------------------------ Option to Buy N/A Cmn. Stk 5,000 I By Spouse (5) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: *** Reporting Person expressly disclaims beneficial ownership of such securities. (1) Information herein based on plan statement as of December 31, 2001. (2) Includes 426,812 shares held directly by spouse; 6,720 shares held by spouse, jointly with grandson; 3,953,256 shares held directly by Trust for daughter, Robin Robinson with spouse as Trustee; and 4,026,992 shares held directly by Trust for daughter, Jill Robinson with spouse as Trustee. (3) Reporting person individually holds a 24% interest in partnership. The remaining partnerships are held in equal shares by Trust for benefit of the reporting person's daughters, with the reporting person's spouse as Trustee. The reporting person disclaims beneficial ownership for 76% of the securities held by Gulf Capital Services, representing the Trusts' pro- portionate partnership interest. (4) Options to buy Common Stock, granted at excersise price of $3.374 per share under the Atlantic American Corporation 1992 Incentive Plan. (5) Granted pursuant to the Company's 1996 Director Stock Option Plan at option prices ranging from $1.90 to $4.4375. /s/ 02/04/03 - --------------------------------------------- ----------------------- **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 provided is insufficient, see Instruction 6 for procedure. Alternatively, this Form is permitted to be submitted to the Commission in electronic format at the option of the reporting person pursuant to rule 101(b)(4) of Regulation S-T. Page 2 of 2 (122797DTI) -----END PRIVACY-ENHANCED MESSAGE-----