4 1 jan2003_form4.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* Skillern Frank L -------------------------------------------------------------------------------- (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 01/20/2003 -------------------------------------------------------------------------------- 5. If Amendment, Date of Original (Month/Day/Year) -------------------------------------------------------------------------------- 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) ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
* 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) ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ Non-Emp- $14.41 01/20/03 A 6,700 (1) 01/19/15 Common 6,700 6,700 D loyee Dir- Stock ector Stock Option (Right to Buy) ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: (1) Option vests in three (3) equal annual installments beginning 1/20/2004. /s/ Cheryl A. Thomson 01/22/03 --------------------------------------------- ----------------------- **Signature of Reporting Person Date Attorney-in-Fact ** 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