-----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, F47Xftsgp8KJgXOANglOct5kt25cQldxRJQqd8piR/Exsd5AJv6Wy19WqBPmGet5 xAify5V5edLatY/g7hF1KA== 0000878897-03-000051.txt : 20030213 0000878897-03-000051.hdr.sgml : 20030213 20030213171301 ACCESSION NUMBER: 0000878897-03-000051 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20021231 FILED AS OF DATE: 20030213 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: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 001-13154 FILM NUMBER: 03560886 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: MILLER SAMUEL V CENTRAL INDEX KEY: 0001081113 RELATIONSHIP: OFFICER FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: AMERICAN MEDICAL SECURITY GROUP INC STREET 2: 3100 AMS BLVD CITY: GREEN BAY STATE: WI ZIP: 54313 BUSINESS PHONE: 9206615418 MAIL ADDRESS: STREET 1: AMERICAN MEDICAL SECURITY GROUP INC STREET 2: 3100 AMS BLVD CITY: GREEN BAY STATE: WI ZIP: 54313 5 1 svmform502.txt AMERICAN MEDICAL SECURITY GROUP, INC. ------------------------------ OMB APPROVAL ------------------------------ OMB Number: 3235-0362 Expires: January 31, 2005 Estimated average burden hours per response.........1.0 ------------------------------ UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, DC 20549 FORM 5 ANNUAL 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(h) 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). |_| Form 3 Holdings Reported |_| Form 4 Transactions Reported - -------------------------------------------------------------------------------- 1. Name and Address of Reporting Person* Miller Samuel V. - -------------------------------------------------------------------------------- (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. I.R.S. Identification Number of Reporting Person, if an entity (Voluntary) - -------------------------------------------------------------------------------- 4. Statement for Month/Year December, 2002 - -------------------------------------------------------------------------------- 5. If Amendment, Date of Original (Month/Year) - -------------------------------------------------------------------------------- 6. Relationship of Reporting Person(s) to Issuer (Check all applicable) |x| Director |_| 10% Owner |x| Officer (give title below) |_| Other (specify below) Chairman, President and Chief Executive Officer - -------------------------------------------------------------------------------- 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- 7. Securities Acquired (A) Amount of ship Nature of 2. 2A. or Disposed of (D) Securities Form: Indirect Trans- Deemed (Instr. 3, 4 and 5) Beneficially Direct Bene- action Execution 3. Owned at end (D) or ficial 1. Date Date, If Transaction (A) of Issuer's Indirect Owner- Title of Security (month/ any (month/ Code or Fiscal Year (I) ship (Instr. 3) day/year) day/year) (Instr.8) Amount (D) Price (Instr. 3 & 4) (Instr.4) (Instr.4) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
* If the form is filed by more than one reporting person, see instruction 4(b)(v). FORM 5 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================
10. 9. Owner- Number ship 2. of of Conver- 5. 7. Deriv- Deriv- 11. sion Number of Title and Amount ative ative Nature or Derivative 6. of Underlying 8. Secur- Secur- of Exer- 3A. Securities Date Securities Price ities ity: In- cise Deemed Acquired (A) Exercisable and (Instr. 3 and 4) of Bene- Direct direct Price 3. Execut- 4. or Disposed Expiration Date ---------------- Deriv- ficially (D) or Bene- 1. of Trans- ion Trans- of(D) (Month/Day/Year) Amount ative Owned In- ficial Title of Deriv- action Date if action (Instr. 3, ---------------- or Secur- at End direct Owner- Derivative ative Date any Code 4 and 5) Date Expira- Number ity of Year (I) ship Security Secur- (mm/dd/ (mm/dd/ (Instr. Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity yy) yy) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ Employee $12.25 1/10/02 A 160,000 (1) 1/9/14 Common 160,000 160,000 D Stock Option Stock (Right to Buy) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: (1) Option vests in four (4) equal annual installments beginning 1/10/03. /s/ Samuel V. Miller 2/12/03 - --------------------------------------------- ----------------------- **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. -----END PRIVACY-ENHANCED MESSAGE-----