-----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, KjE1Gk6BGn7FO3AQvtGNT2cE7jWtXdF2Z3QLPT7czPMNf1nrWaq9x4dtgDYKb68r fZ16F1wh94cf44rB2egYGA== 0000878897-04-000057.txt : 20041214 0000878897-04-000057.hdr.sgml : 20041214 20041214174012 ACCESSION NUMBER: 0000878897-04-000057 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20041213 FILED AS OF DATE: 20041214 DATE AS OF CHANGE: 20041214 ISSUER: 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 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: OWNER DATA: COMPANY CONFORMED NAME: BALLOU ROGER H CENTRAL INDEX KEY: 0001158369 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-13154 FILM NUMBER: 041202673 BUSINESS ADDRESS: STREET 1: C/O CDI CORP STREET 2: 1717 ARCH ST. 35TH FL CITY: PHILADELPHIA STATE: PA ZIP: 19103 BUSINESS PHONE: 2155692200 MAIL ADDRESS: STREET 1: C/O CDI CORP STREET 2: 1717 ARCH ST 35TH FL CITY: PHILADELPHIA STATE: PA ZIP: 19103 4 1 primary_doc.xml PRIMARY DOCUMENT X0202 4 2004-12-13 1 0000878897 AMERICAN MEDICAL SECURITY GROUP INC AMZ 0001158369 BALLOU ROGER H 3100 AMS BOULEVARD GREEN BAY WI 54313 1 0 0 0 Common Stock 2004-12-13 4 D 0 7921.81 32.75 D 0 D Employee stock option (right to buy) 5.1875 2004-12-13 4 D 0 3333 27.5625 D 2012-11-16 Common Stock 3333 0 D Employee stock option (right to buy) 10.2 2004-12-13 4 D 0 8000 22.55 D 2013-11-28 Common Stock 8000 0 D Employee stock option (right to buy) 14.41 2004-12-13 4 D 0 6700 18.34 D 2015-01-19 Common Stock 6700 0 D Employee stock option (right to buy) 10.25 2004-12-13 4 D 0 5000 22.5 D 2010-09-27 Common Stock 5000 0 D This option vested in three equal annual installments beginning November 17, 2001 This option vested in three equal annual installments beginning November 29, 2002. This option vested in three equal annual installments beginning January 20, 2003. This option vested in three equal annual installments beginning September 28, 1999. /s/Cheryl A. Thomson Attorney-in-Fact 2004-12-13 -----END PRIVACY-ENHANCED MESSAGE-----