-----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, KN3a56mvbijObVq3iRpEP+7SMVHYLwkdKcFhRqHVCaC86eFY65+lNLNDzOQuBvqj Hk6P1Z2FzzdJIU+OuJlLJg== 0000878897-03-000012.txt : 20030114 0000878897-03-000012.hdr.sgml : 20030114 20030113164225 ACCESSION NUMBER: 0000878897-03-000012 CONFORMED SUBMISSION TYPE: 4/A PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20021231 FILED AS OF DATE: 20030113 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: AMERICAN MEDICAL SECURITY GROUP INC CENTRAL INDEX KEY: 0000878897 STANDARD INDUSTRIAL CLASSIFICATION: HOSPITAL & MEDICAL SERVICE PLANS [6324] IRS NUMBER: 391431799 STATE OF INCORPORATION: WI FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4/A SEC ACT: 1934 Act SEC FILE NUMBER: 001-13154 FILM NUMBER: 03512420 BUSINESS ADDRESS: STREET 1: 3100 AMS BLVD CITY: GREEN BAY STATE: WI ZIP: 54313 BUSINESS PHONE: 9206611111 MAIL ADDRESS: STREET 1: 3100 AMS BLVD CITY: GREEN BAY STATE: WI ZIP: 54313 FORMER COMPANY: FORMER CONFORMED NAME: UNITED WISCONSIN SERVICES INC /WI DATE OF NAME CHANGE: 19930328 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: SCHREYER HT RICHARD CENTRAL INDEX KEY: 0001181983 STANDARD INDUSTRIAL CLASSIFICATION: UNKNOWN SIC - 0000 [0000] RELATIONSHIP: DIRECTOR STATE OF INCORPORATION: VA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4/A BUSINESS ADDRESS: STREET 1: C/O AMERICAN MECICAL SECURITY GROUP INC STREET 2: 3100 AMS BLVD CITY: GREEN BAY STATE: WI ZIP: 54313 BUSINESS PHONE: 9206611111 MAIL ADDRESS: STREET 1: C/O AMERICAN MECICAL SECURITY GROUP INC STREET 2: 3100 AMS BLVD CITY: GREEN BAY STATE: WI ZIP: 54313 4/A 1 fourthqtr02_form4a.txt AMERICAN MEDICAL SECURITY GROUP, INC. -------------------------- OMB APPROVAL -------------------------- OMB Number: 3235-0287 Expires: January 31, 2005 Estimated average burden hours per response.... 0.5 -------------------------- U.S. SECURITIES AND EXCHANGE COMMISSION Washington, DC 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 box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). - -------------------------------------------------------------------------------- 1. Name and Address of Reporting Person* Schreyer H.T. Richard - -------------------------------------------------------------------------------- (Last) (First) (Middle) 3100 AMS Boulevard - -------------------------------------------------------------------------------- (Street) Green Bay WI 54313 - -------------------------------------------------------------------------------- (City) (State) (Zip) - -------------------------------------------------------------------------------- 2. Issuer Name and Ticker or Trading Symbol American Medical Security Group, Inc. (AMZ) - -------------------------------------------------------------------------------- 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) - -------------------------------------------------------------------------------- 4. Statement for Month/Day/Year 12/31/2002 - -------------------------------------------------------------------------------- 5. If Amendment, Date of Original (Month/Day/Year) 1/3/2003 - -------------------------------------------------------------------------------- 6. Relationship of Reporting Person to Issuer (Check all applicable) [X] Director [_] 10% Owner [_] Officer (give title below) [_] Other (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 ================================================================================
6. 4. 5. Owner- Securities Acquired (A) or Amount of ship 3. Disposed of (D) Securities Form: 7. 2A. Transaction (Instr. 3, 4 and 5) Beneficially Direct Nature of 2. Deemed Exec- Code ------------------------------- Owned Follow- (D) or Indirect 1. Transaction ution Date, (Instr. 8) (A) ing Reported Indirect Beneficial Title of Security Date if any ------------ Amount or Price Transactions (I) Ownership (Instr. 3) (mm/dd/yy) (mm/dd/yy) Code V (D) (Instr.3 & 4) (Instr.4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 12/31/02 A 352.29 A $13.98 5,829.81 D - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
* 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. (Print or Type Response) (Over) 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 Deriv- Form 2. ative of Conv- 5. 7. Secur- Deriv- 11. ersion Number of Title and Amount ities ative Nature or Derivative 6. of Underlying 8. Bene- Secur- of Exer- 3A. 4. Securities Date Securities Price ficially ity: In- cise 3. Deemed Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of Owned Direct direct 1. Price Trans- Exec- action or Disposed Expiration Date ---------------- Deriv- Follow- (D) or Bene- Title of of action ution Code of(D) (Month/Day/Year) Amount ative ing Rep- In- ficial Deriv- Deriv- Date Date, (Instr. (Instr. 3, ---------------- or Secur- orted direct Owner- ative Sec- ative (Month/ if any 8) 4 and 5) Date Expira- Number ity Trans- (I) ship urity Secur- Day/ (mm/dd ------ ------------ Exer- tion of (Instr. action(s) (Instr. (Instr. (Instr.3) ity Year) /yy) Code V (A) (D) cisable Date Title Shares 5) (Instr.4) 4) 4) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: /s/ H.T. Richard Schreyer 1/09/03 - --------------------------------------------- ----------------------- **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. 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 -----END PRIVACY-ENHANCED MESSAGE-----