-----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, SrJRI7vpQvatieuFRUDu+KBFFRqsgUSKpXZKJd1jPIdPdFblYbhfqQfsL22OgMqY l2zJ0jh2p34QGqIvEt9gbA== 0000878897-03-000052.txt : 20030213 0000878897-03-000052.hdr.sgml : 20030213 20030213171358 ACCESSION NUMBER: 0000878897-03-000052 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: 03560904 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: EVASON KENNETH L CENTRAL INDEX KEY: 0001181979 STANDARD INDUSTRIAL CLASSIFICATION: UNKNOWN SIC - 0000 [0000] RELATIONSHIP: OTHER STATE OF INCORPORATION: VA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 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 5 1 kleform502.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 |X| 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* Evason Kenneth 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. 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) |_| Director |_| 10% Owner |_| Officer (give title below) |X| Other (specify below) Former Director - -------------------------------------------------------------------------------- 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) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ Non-Emp- $15.34 3/22/02 A 5,000 (1) 3/21/14 Common 5,000 5,000 D loyee Stock (2) Stock (2) Option (Right to Buy) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: (1) Option vests in three (3) equal annual installments beginning 3/22/03. (2) Pursuant to the terms of the stock option, the reported stock options were cancelled for no value on 1/3/03 in connection with the reporting person's resignation as a director of AMZ. /s/ Cheryl A. Thomson 2/13/02 - --------------------------------------------- ----------------------- **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. POWER OF ATTORNEY Know all by these presents, that the undersigned hereby constitutes and appoints each of Timothy J. Moore and Cheryl A. Thomson, signing singly, the undersigned's true and lawful attorney-in-fact to: (1) execute for and on behalf of the undersigned, in the undersigned's capacity as an officer and/or director of the Company, Forms 3, 4 and 5 in accordance with Section 16(a) of the Securities Exchange Act of 1934 and the rules thereunder; (2) do and perform any and all acts for and on behalf of the undersigned which may be necessary or desirable to complete and execute any such Form 3, 4 or 5 and timely file such form with the United States Securities and Exchange Commission and any stock exchange or similar authority; and (3) take any other action of any type whatsoever in connection with the foregoing which, in the opinion of such attorney-in-fact, may be of benefit to, in the best interest of, or legally required by, the undersigned, it being understood that the documents executed by such attorney-in-fact on behalf of the undersigned pursuant to this Power of Attorney shall be in such form and shall contain such terms and conditions as such attorney-in-fact may approve in such attorney-in-fact's discretion. The undersigned hereby grants to each such attorney-in-fact full power and authority to do and perform any and every act and thing whatsoever requisite, necessary, or proper to be done in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as the undersigned might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that such attorney-in-fact's substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers herein granted. The undersigned acknowledges that the foregoing attorneys-in-fact, in serving in such capacity at the request of the undersigned, are not assuming, nor is the Company assuming, any of the undersigned's responsibilities to comply with Section 16 of the Securities Exchange Act of 1934. This Power of Attorney shall remain in full force and effect until the undersigned is no longer required to file Forms 3, 4 and 5 with respect to the undersigned's holdings of and transactions in securities issued by the Company, unless earlier revoked by the undersigned in a signed writing delivered to the foregoing attorneys-in-fact. IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be executed as of this 28th day of March, 2002. /s/ Ken L. Evason ------------------------------------------ Kenneth L. Evason Signature Page 3 -----END PRIVACY-ENHANCED MESSAGE-----