-----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, BdcsPC323in1CgtnX1TIPS5Y1vZ/WcRWAkdtFBHdqPR4LnzzP/yx6xJntZ2W0pRp 2dy6f+9T6CrYYWV6OBKKMg== 0000897069-03-000003.txt : 20030103 0000897069-03-000003.hdr.sgml : 20030103 20030103145029 ACCESSION NUMBER: 0000897069-03-000003 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20021231 FILED AS OF DATE: 20030103 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: BLUE CROSS & BLUE SHIELD UNITED OF WISCONSIN CENTRAL INDEX KEY: 0001034194 RELATIONSHIP: OWNER FILING VALUES: FORM TYPE: 4 BUSINESS ADDRESS: STREET 1: 1515 NORTH RIVERSIDE DRIVE CITY: MILWAUKEE STATE: WI ZIP: 53212 BUSINESS PHONE: 4142266200 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: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-13154 FILM NUMBER: 03502757 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 4 1 irm56.txt FORM 4 ------------------------------ OMB APPROVAL ------------------------------ OMB Number 3235-0287 Expires: January 31, 2005 Estimated average burden hours per response ....... 0.5 ------------------------------ UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 4 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 [_] Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). ________________________________________________________________________________ 1. Name and Address of Reporting Person* BLUE CROSS & BLUE SHIELD UNITED OF WISCONSIN (1) - -------------------------------------------------------------------------------- (Last) (First) (Middle) 401 WEST MICHIGAN STREET - -------------------------------------------------------------------------------- (Street) MILWAUKEE, WI 53203 - -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Issuer Name and Ticker or Trading Symbol AMERICAN MEDICAL SECURITY GROUP, INC. (AMZ) ________________________________________________________________________________ 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) ________________________________________________________________________________ 4. Statement for Month/Day/Year December 31, 2002 ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Day/Year) ================================================================================ 6. Relationship of Reporting Person(s) to Issuer (Check all applicable) [_] Director [X] 10% Owner [_] Officer (give title below) [_] Other (specify below) ________________________________________________________________________________ 7. Individual or Joint/Group Filing (Check applicable line) [_] Form filed by one Reporting Person [X] Form filed by more than one Reporting Person ________________________________________________________________________________ ================================================================================ Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned ================================================================================
5. 6. 2A. 4. Amount of Owner- Deemed Securities Acquired (A) or Securities ship 2. Execution 3. Disposed of (D) Beneficially Form: 7. Transaction Date, if Transaction (Instr. 3, 4 and 5) Owned Follow- Direct Nature of Date any Code ------------------------------- ing Reported (D) or Indirect 1. (Month/ (Month/ (Instr. 8) (A) Transaction(s) Indirect Beneficial Title of Security Day/ Day/ ------------ Amount or Price (Instr. 3 (I) Ownership (Instr. 3) Year) Year) Code V (D) and 4) (Instr.4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 12/31/02 S 149,098 D $13.414(2) 1,382,077 D - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ (1) As a result of the conversion of Blue Cross & Blue Shield United of Wisconsin ("BCBSUW") from a Wisconsin service insurance corporation to a Wisconsin stock insurance corporation, Cobalt Corporation became the owner of 100% of the issued and outstanding common stock of BCBSUW and Wisconsin United for Health Foundation, Inc. ("Foundation") became the owner of 77.5% of the issued and outstanding common stock of Cobalt Corporation. Consequently, Cobalt Corporation became a beneficial owner and the Foundation became an indirect beneficial owner of the Common Stock owned by BCBSUW. (2) Transferred as partial consideration for purchase of assets. ==================================================================================================================================== Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. * If the Form is filed by more than one Reporting Person, see Instruction 4(b)(v). Persons who respond to the collection of information contained in this form are not required to respond (Over) unless the form displays a currently valid OMB control number. SEC 1474 (9-02)
FORM 4 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ====================================================================================================================================
10. 9. Owner- Number ship of Deriv- Form 2. ative of Conver- 5. 7. Secur- Deriv- 11. sion Number of Title and Amount ities ative Nature or 3A. Derivative 6. of Underlying 8. Benefi- Secur- of Exer- Deemed 4. Securities Date Securities Price cially ity: In- cise 3. Execu- Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of Owned Direct direct Price Trans- tion action or Disposed Expiration Date ---------------- Deriv- Following (D) or Bene- 1. of action Date, Code of(D) (Month/Day/Year) Amount ative Reported In- ficial Title of Deriv- Date if any (Instr. (Instr. 3, ---------------- or Secur- Trans- direct Owner- Derivative ative (Month/ (Month/ 8) 4 and 5) Date Expira- Number ity action(s) (I) ship Security Secur- Day/ Day/ ------ ------------ Exer- tion of (Instr (Instr (Instr (Instr (Instr. 3) ity Year) Year) Code V (A) (D) cisable Date Title Shares 5) 4) 4) 4) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ==================================================================================================================================== Explanation of Responses: BLUE CROSS & BLUE SHIELD UNITED OF WISCONSIN ** Intentional misstatements or omissions of facts constitute Federal Criminal Violations. /s/ Gail L. Hanson 1/2/03 ------------------------------------- ---------- See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). ** Signature of Reporting Person Date Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. Page 2
EX-99 3 irm56a.txt JOINT FILER INFORMATION JOINT FILER INFORMATION Name: Cobalt Corporation Address: 401 West Michigan Avenue Milwaukee, Wisconsin 53203 Designated Filer: Blue Cross & Blue Shield United of Wisconsin Issuer and Ticker Symbol: American Medical Security Group, Inc. (AMZ) Date of Event Requiring Statement: December 31, 2002 Signature: COBALT CORPORATION By: /s/ Gail L. Hanson ------------------------------------ Gail L. Hanson Senior Vice President Name: Wisconsin United for Health Foundation, Inc. Address: 10 East Doty Street, Suite 600 Madison, Wisconsin 53701 Designated Filer: Blue Cross & Blue Shield United of Wisconsin Issuer and Ticker Symbol: American Medical Security Group, Inc. (AMZ) Date of Event Requiring Statement: December 31, 2002 Signature: WISCONSIN UNITED FOR HEALTH FOUNDATION, INC. By: /s/ Katherine Hudson ------------------------------------ Katherine Hudson Secretary -----END PRIVACY-ENHANCED MESSAGE-----