-----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, Gof6nfrSLdYf/jEnBMy2CCXfCS/mLBcct/7DIMYN3Jpfc2IqSSpiOTDgDFm1BIDs PG2AyDs+5aXbEo8eFBPQhg== 0000878897-03-000066.txt : 20030416 0000878897-03-000066.hdr.sgml : 20030416 20030416160144 ACCESSION NUMBER: 0000878897-03-000066 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20030414 FILED AS OF DATE: 20030416 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: LOMBARDI JOHN R CENTRAL INDEX KEY: 0001227719 RELATIONSHIP: OFFICER FILING VALUES: FORM TYPE: 3 BUSINESS ADDRESS: STREET 1: 3100 AMS BOULEVARD CITY: GREEN BAY STATE: WI ZIP: 54313 BUSINESS PHONE: 920 661 1111 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: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-13154 FILM NUMBER: 03652691 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 3 1 form3jrl041503.txt AMERICAN MEDICAL SECURITY GROUP, INC. ------------------------------ OMB APPROVAL ------------------------------ OMB Number: 3235-0104 Expires: January 31, 2005 Estimated average burden hours per response.........0.5 ------------------------------ UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, DC 20549 FORM 3 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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 (Print of Type Responses) ________________________________________________________________________________ 1. Name and Address of Reporting Person* Lombardi John R. - -------------------------------------------------------------------------------- (Last) (First) (Middle) 3100 AMS Boulevard - -------------------------------------------------------------------------------- (Street) Green Bay WI 54313 - -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Date of Event Requiring Statement (Month/Day/Year) 4/14/03 ________________________________________________________________________________ 3. I.R.S. Identification Number of Reporting Person, if an entity (voluntary) ________________________________________________________________________________ 4. Issuer Name and Ticker or Trading Symbol American Medical Security Group, Inc. (AMZ) ________________________________________________________________________________ 5. Relationship of Reporting Person(s) to Issuer (Check all applicable) |_| Director |_| 10% Owner |x| Officer (give title below) |_| Other (specify below) Executive Vice President, Chief Financial Officer & Treasurer ________________________________________________________________________________ 6. If Amendment, Date of Original (Month/Day/Year) ________________________________________________________________________________ 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 Beneficially Owned ================================================================================
3. Ownership Form: 2. Amount of Securities Direct (D) or 1. Title of Security Beneficially Owned Indirect (I) 4. Nature of Indirect Beneficial Ownership (Instr. 4) (Instr. 4) (Instr. 5) (Instr. 5) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ No securities owned - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
FORM 3 (continued) Table II -- Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================
5. Owner- 3. Title and Amount of Securities ship Underlying Derivative Security Form of 2. Date Exercisable (Instr. 4) Derivative and Expiration Date --------------------------------- 4. Conver- Securities: (Month/Day/Year) Amount sion or Direct 6. Nature of ---------------------- or Exercise (D) or Indirect Date Expira- Number Price of Indirect Beneficial 1. Title of Derivative Exer- tion of Derivative (I) Ownership Security (Instr. 4) cisable Date Title Shares Security (Instr. 5) (Instr. 5) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. Explanation of Responses: /s/ J R Lombardi 4/15/2003 - --------------------------------------------- ----------------------- **Signature of Reporting Person Date John R. Lombardi * If the form is filed by more than one reporting person, see Instruction 5(b)(v). ** 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 is insufficient, see Instruction 6 for procedure. -----END PRIVACY-ENHANCED MESSAGE-----