-----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, LB9sJTRVi5uGIA6tVYyvXgeLjJjHv+GTramtbRZwLd/R37j9Zd/lyDQQY9CZYXHl thOEveTX+q85iu5tHKLakg== 0001047469-04-036933.txt : 20041213 0001047469-04-036933.hdr.sgml : 20041213 20041213164235 ACCESSION NUMBER: 0001047469-04-036933 CONFORMED SUBMISSION TYPE: 15-12G PUBLIC DOCUMENT COUNT: 1 FILED AS OF DATE: 20041213 DATE AS OF CHANGE: 20041213 EFFECTIVENESS DATE: 20041213 FILER: 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: 15-12G SEC ACT: 1934 Act SEC FILE NUMBER: 000-19506 FILM NUMBER: 041199200 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 15-12G 1 a2148408z15-12g.htm 15-12G

UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

FORM 15

CERTIFICATION AND NOTICE OF TERMINATION OF REGISTRATION UNDER
SECTION 12(g) OF THE SECURITIES EXCHANGE ACT OF 1934 OR SUSPENSION OF
DUTY TO FILE REPORTS UNDER SECTIONS 13 AND 15(d) OF THE
SECURITIES EXCHANGE ACT OF 1934.

Commission File Number: 1-13154

American Medical Security Group, Inc.
(Exact name of registrant as specified in its charter)

3100 AMS Boulevard
Green Bay, WI 54313
(920) 661-1111
(Address, including zip code, and telephone number, including area code, of registrant's principal executive offices)

Common Stock, no par value
(Title of each class of securities covered by this Form)

None
(Titles of all other classes of securities for which a duty to file reports under section 13(a) or 15(d) remains)

        Please place an X in the box(es) to designate the appropriate rule provision(s) relied upon to terminate or suspend the duty to file reports:

Rule 12g-4(a)(1)(i) ý   Rule 12h-3(b)(1)(i) ý
Rule 12g-4(a)(1)(ii) o   Rule 12h-3(b)(1)(ii) o
Rule 12g-4(a)(2)(i) o   Rule 12h-3(b)(2)(i) o
Rule 12g-4(a)(2)(ii) o   Rule 12h-3(b)(2)(ii) o
      Rule 15d-6 o

        Approximate number of holders of record as of the certification or notice date:        One (1)

        Pursuant to the requirements of the Securities Exchange Act of 1934, American Medical Security Group, Inc. has caused this certification/notice to be signed on its behalf by the undersigned duly authorized person.

Date: December 13, 2004   By: /s/  MICHAEL E. JANSEN      
Michael E. Jansen
Assistant Secretary


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