5 1 d5.txt ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHI /------------------------------/ / OMB APPROVAL / /------------------------------/ / OMB Number: 3235-0362 / / Expires: September 30, 1998 / / Estimated average burden / / hours per response...... 1.0 / /------------------------------/ +--------+ UNITED STATES | FORM 5 | SECURITIES AND EXCHANGE COMMISSION +--------+ Washington, D.C. 20549 [_] Check this box if no longer subject ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP to Section 16. Form 4 or Form 5 Filed pursuant to Section 16(a) of the Securities obligations may Exchange Act of 1934, Section 17(a) of the continue. See Public Utility Holding Company Act of 1935 or Instruction 1(b). Section 30(f) of the Investment Company Act of 1940 [_] Form 3 Holdings Reported [_] Form 4 Transactions Reported -------------------------------------------------------------------------------- 1. Name and Address of Reporting Person* Dailey, Roger E. -------------------------------------------------------------------------------- (Last) (First) (Middle) 4645 Pinot Noir Drive -------------------------------------------------------------------------------- (Street) Brazelton GA 30517 -------------------------------------------------------------------------------- (City) (State) (Zip) 2. Issuer Name and Ticker or Trading Symbol Mutual Risk Management Ltd. (MM) ----------------------------------- 3. I.R.S. Identification Number of Reporting Person, if an entity (Voluntary) -------------- 4. Statement for Month/Year December 31, 2001 --------------------------------------------------- 5. If Amendment, Date of Original (Month/Year) -------------------------------- 6. Relationship of Reporting Person(s) to Issuer (Check all applicable) [X] Director [_] Officer [_] 10% Owner [_] Other (give title below) (specify below) 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
------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Trans- 3. Trans- 4. Securities Acquired (A) 5. Amount of 6. Owner- 7. Nature (Instr. 3) action action or Disposed of (D) Securities ship of In- Date Code (Instr. 3, 4 and 5) Beneficially Form: direct (Instr. 8) Owned at the Direct Bene- (Month/ end of (D) or ficial Day/ Issuer's Indirect Owner- Year) (A) or Fiscal Year (I) ship Amount (D) Price (Instr. 3 and 4) (Instr. 4) (Instr. 4) ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 04/17/01 A 1,189 A D ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 07/03/01 A 967 A D ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 10/01/01 A 1,156 A 38,945 D ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------
* If the form is filed by more than one reporting person, see instruction 4(b)(v). 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. (Over) SEC 2270(7-97) FORM 5 (continued) Table II--Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g. puts, calls, warrants, options, convertible securities)
----------------------------------------------------------------------------------------------------------------------------- 1. Title of Derivative 2. Conver- 3. Trans- 4. Transac- 5. Number of Deriv- Security (Instr. 3) sion or action tion Code ative Securities Exercise Date (Instr. 8) Acquired (A) or Price of (Month/ Disposed of (D) Deriv- Day/ (Instr. 3, 4, and 5) ative Year) Security --------------------------- (A) (D) ------------------------------------------------------------------------------------------------------------------------------ Non-Qualified Stock Option $ 8.960000 12/03/01 A 15,000 (right to buy) ------------------------------------------------------------------------------------------------------------------------------ Non-Qualified Stock Option $14.750000 (right to buy) ------------------------------------------------------------------------------------------------------------------------------ Non-Qualified Stock Option $16.500000 (right to buy) ------------------------------------------------------------------------------------------------------------------------------ Non-Qualified Stock Option $27.812500 (right to buy) ------------------------------------------------------------------------------------------------------------------------------ Non-Qualified Stock Option $37.250000 (right to buy) ------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ 6. Date Exer- 7. Title and Amount of 8. Price 9. Number 10. Owner- 11. Na- cisable and Underlying Securities of of Deriv- ship Form ture Expiration (Instr. 3 and 4) Deriv- ative of De- of In- Date ative Secur- rivative direct (Month/Day/ Secur- ities Secu- Bene- Year) ity Bene- rity: ficial (Instr. 5) ficially Direct Owner- -------------------------------------------- Owned (D) or ship Date Expira- Amount or at End Indi- (Instr. 4) Exer- tion Title Number of of Year rect (I) cisable Date Shares (Instr. 4) (Instr. 4) ------------------------------------------------------------------------------------------------------------------------------------ 12/03/06 Common Stock 15,000 15,000 D ------------------------------------------------------------------------------------------------------------------------------------ 12/01/04 Common Stock 7,500 7,500 D ------------------------------------------------------------------------------------------------------------------------------------ 12/01/05 Common Stock 15,000 15,000 D ------------------------------------------------------------------------------------------------------------------------------------ 12/01/02 Common Stock 7,500 7,500 D ------------------------------------------------------------------------------------------------------------------------------------ 12/01/03 Common Stock 7,500 7,500 D ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ Explanation of Responses: ** Intentional misstatements or omissions of facts constitute Federal -------------------------------- ----------------- Criminal Violations. **Signature of Reporting Person Date 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. Potential persons who are to respond to the collection of information contained in this form are not reguired to respond unless the form displays a currently valid OMB Number. Page 2 SEC 2270 (7-97)