-----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, H0yFBLX27DGqdluJTabFtIgcj9ePjFs/mQAXaZeb0q5KOdHdQ16PL90jlMHZumux 5qFWchyMS9Frexct0j4Xyw== 0000878897-04-000069.txt : 20041215 0000878897-04-000069.hdr.sgml : 20041215 20041215115319 ACCESSION NUMBER: 0000878897-04-000069 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20041213 FILED AS OF DATE: 20041215 DATE AS OF CHANGE: 20041215 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: MODAFF JAMES C CENTRAL INDEX KEY: 0001181964 STATE OF INCORPORATION: VA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-13154 FILM NUMBER: 041203800 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 MEDICAL SECURITY GROUP INC STREET 2: 3100 AMS BLVD CITY: GREEN BAY STATE: WI ZIP: 54313 4 1 primary_doc.xml PRIMARY DOCUMENT X0202 4 2004-12-13 1 0000878897 AMERICAN MEDICAL SECURITY GROUP INC AMZ 0001181964 MODAFF JAMES C C/O AMERICAN MEDICAL SECURITY GROUP INC 3100 AMS BLVD GREEN BAY WI 54313 0 1 0 0 Exec VP & Chief Actuary Employee Stock Option (right to buy) 10.75 2004-12-13 4 D 0 110000 22 D 2011-08-01 Common Stock 110000 0 D Employee stock option (right to buy) 5.8125 2004-12-13 4 D 0 68000 26.9375 D 2011-11-16 Common Stock 68000 0 D Employee Stock Option (right to buy) 5.1875 2004-12-13 4 D 0 35000 27.5625 D 2012-11-16 Common Stock 35000 0 D Employee Stock Option (right to buy) 10.2 2004-12-13 4 D 0 50000 22.55 D 2013-11-28 Common Stock 50000 0 D Employee Stock Option (right to buy) 14.41 2004-12-13 4 D 0 42500 18.34 D 2015-01-19 Common Stock 42500 0 D This option vested in four equal annual installments beginning August 2, 2000. This option vested in four equal annual installments beginning November 17, 2000. This option vested in four equal annual installments beginning November 17, 2001. This option vested in four equal annual installments beginning November 29, 2002. This option vested in four equal annual installments beginning January 20, 2003. /s/Cheryl A. Thomson Attorney-in-fact 2004-12-15 -----END PRIVACY-ENHANCED MESSAGE-----