-----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, La0NlErnZ5AIXOd3Y1Ues727KiNJ7WN8fbupBBiGRZeFSALX8BnXQeSnNwuPP6/h FPpHRkt7YsUux9rmvQRSrA== 0000878897-99-000004.txt : 19990308 0000878897-99-000004.hdr.sgml : 19990308 ACCESSION NUMBER: 0000878897-99-000004 CONFORMED SUBMISSION TYPE: SC 13G PUBLIC DOCUMENT COUNT: 1 FILED AS OF DATE: 19990305 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: SC 13G SEC ACT: SEC FILE NUMBER: 005-41965 FILM NUMBER: 99557968 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 FILED BY: COMPANY DATA: COMPANY CONFORMED NAME: MILLER SAMUEL V CENTRAL INDEX KEY: 0001081113 STANDARD INDUSTRIAL CLASSIFICATION: [] FILING VALUES: FORM TYPE: SC 13G BUSINESS ADDRESS: STREET 1: AMERICAN MEDICAL SECURITY GROUP INC STREET 2: PO BOX 19032 CITY: GREEN BAY STATE: WI ZIP: 54307-9032 BUSINESS PHONE: 9206611333 MAIL ADDRESS: STREET 1: AMERICAN MEDICAL SECURITY GROUP INC STREET 2: PO BOX 19032 CITY: GREEN BAY STATE: WI ZIP: 19032 SC 13G 1 UNITED STATES SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 SCHEDULE 13G INFORMATION STATEMENT TO BE INCLUDED IN STATEMENTS FILED PURSUANT TO RULES 13D-1(b)(c) AND (d) AND AMENDMENTS THERETO FILED PURSUANT TO RULE 13d-2(b) (AMENDMENT NO. )* AMERICAN MEDICAL SECURITY GROUP, INC. ------------------------------------------------------------------------------- (Name of Issuer) COMMON STOCK ------------------------------------------------------------------------------- (Title of Class of Securities) 02744P101 ------------------------------------------------------------------------------- (CUSIP Number) December 31, 1998 ------------------------------------------------------------------------------- (Date of Event Which Requires Filing of This Statement) Check the appropriate box to designate the rule pursuant to which this Schedule is filed: [ ] Rule 13d-1(b) [ ] Rule 13d-(c) [X] Rule 13d-1(d) - ---------------- * The remainder of this cover page shall be filled out for a reporting person's initial filing on this form with respect to the subject class of securities, and for any subsequent amendment containing information which would alter the disclosures provided in a prior cover page. The information required in the remainder of this cover page shall not be deemed to be "filed" for the purpose of Section 18 of the Securities Exchange Act of 1934 ("Act") or otherwise subject to the liabilities of that section of the Act but shall be subject to all other provisions of the Act (however, see the Notes). 2 - -------------------- ----------------- CUSIP NO. 02744P101 13G PAGE 2 OF 5 PAGES - -------------------- ----------------- - -------------------------------------------------------------------------------- 1 NAME OF REPORTING PERSON I.R.S. IDENTIFICATION OF ABOVE PERSON Samuel V. Miller - -------------------------------------------------------------------------------- 2 CHECK THE APPROPRIATE BOX IF A MEMBER OF A GROUP (a) [ ] (b) [ ] - -------------------------------------------------------------------------------- 3 SEC USE ONLY - -------------------------------------------------------------------------------- 4 CITIZENSHIP OR PLACE OF ORGANIZATION U.S.A. - -------------------------------------------------------------------------------- 5 SOLE VOTING POWER 972,175 NUMBER OF ---------------------------------------------------- SHARES 6 SHARED VOTING POWER BENEFICIALLY OWNED BY 2,000 EACH ---------------------------------------------------- REPORTING 7 SOLE DISPOSITIVE POWER PERSON WITH 972,175 ---------------------------------------------------- 8 SHARED DISPOSITIVE POWER 2,000 - -------------------------------------------------------------------------------- 9 AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH REPORTING PERSON 974,175 - -------------------------------------------------------------------------------- 10 CHECK BOX IF THE AGGREGATE AMOUNT IN ROW (9) EXCLUDES CERTAIN SHARES [ ] - -------------------------------------------------------------------------------- 11 PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW (9) 5.5% - -------------------------------------------------------------------------------- 12 TYPE OF REPORTING PERSON IN - -------------------------------------------------------------------------------- 2 3 ITEM 1 (a) NAME OF ISSUER: American Medical Security Group, Inc. (b) ADDRESS OF ISSUER'S PRINCIPAL EXECUTIVE OFFICES: 3100 AMS Boulevard Green Bay, Wisconsin 54313 ITEM 2 (a) NAME OF PERSON FILING: Samuel V. Miller (b) ADDRESS OF PRINCIPAL BUSINESS OFFICE: 3100 AMS Boulevard Green Bay, Wisconsin 54313 (c) CITIZENSHIP: U.S.A. (d) TITLE OF CLASS OF SECURITIES: Common Stock (e) CUSIP NUMBER: 02744P101 ITEM 3 IF THIS STATEMENT IS FILED PURSUANT TO RULE 13D-1(b), OR 13d-2(b), CHECK WHETHER THE PERSON FILING IS A: (a) [ ] Broker or dealer registered under Section 15 of the Exchange Act; (b) [ ] Bank as defined in Section 3(a)(6) of the Exchange Act; (c) [ ] Insurance company as defined in Section 3(a)(19) of the Act; (d) [ ] Investment company registered under Section 8 of the Investment Company Act; (e) [ ] Investment adviser registered under Section 203 of the Investment Advisors Act of 1940; (f) [ ] Employee benefit plan or endowment fund in accordance with Rule 13d-1(b)(1)(ii)(F); (g) [ ] Parent holding company or control person, in accordance with 13d-1(b)(ii)(G); (h) [ ] Savings association as defined in Section 3(b) of the Federal Deposit Insurance Act; (i) [ ] Church plan that is excluded from the definition of an investment company under Section 3(c)(14) of the Investment Company Act; (j) [ ] Group, in accordance with Rule13d-1(b)(1)(ii) (H). If this statement is filed pursuant to Rule 13d-1(c), check this box. [ ] 3 4 ITEM 4 OWNERSHIP. (a) Amount beneficially owned: 974,175* *Includes 972,175 shares which may be acquired pursuant to options which were exercisable within 60 days of December 31, 1998. (b) Percent of Class: 5.5% (c) Number of shares as to which such person has: (i) Sole power to vote or direct the vote: 972,175 (ii) Shared power to vote: 2,000 (iii) Sole power to dispose or direct the disposition of: 972,175 (iv) Shared power to dispose or direct the disposition of: 2,000 ITEM 5 OWNERSHIP OF FIVE PERCENT OR LESS OF A CLASS. If this statement is being filed to report the fact that as of the date hereof the reporting person has ceased to be the beneficial owner of more than five percent of the class of securities, check the following [ ]. ITEM 6 OWNERSHIP OF MORE THAN FIVE PERCENT ON BEHALF OF ANOTHER PERSON. Not Applicable ITEM 7 IDENTIFICATION AND CLARIFICATION OF THE SUBSIDIARY WHICH ACQUIRED THE SECURITY BEING REPORTED ON BY THE PARENT HOLDING COMPANY. Not Applicable. ITEM 8 IDENTIFICATION AND CLARIFICATION OF MEMBERS OF THE GROUP. Not Applicable. ITEM 9 NOTICE OF DISSOLUTION OF GROUP. Not Applicable. ITEM 10 CERTIFICATION. Not Applicable 4 5 SIGNATURE After reasonable inquiry and to the best of my knowledge and belief, I certify that the information set forth in this statement is true, complete and correct. March 5, 1999 ----------------------------- (Date) /s/ SAMUEL V. MILLER ----------------------------- Samuel V. Miller 5 -----END PRIVACY-ENHANCED MESSAGE-----