0000895930-16-000103.txt : 20160202 0000895930-16-000103.hdr.sgml : 20160202 20160202165218 ACCESSION NUMBER: 0000895930-16-000103 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20151231 FILED AS OF DATE: 20160202 DATE AS OF CHANGE: 20160202 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: AMSURG CORP CENTRAL INDEX KEY: 0000895930 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-OFFICES & CLINICS OF DOCTORS OF MEDICINE [8011] IRS NUMBER: 621493316 STATE OF INCORPORATION: TN FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 1A BURTON HILLS BLVD. CITY: NASHVILLE STATE: TN ZIP: 37215 BUSINESS PHONE: 615-665-1283 MAIL ADDRESS: STREET 1: 1A BURTON HILLS BLVD. CITY: NASHVILLE STATE: TN ZIP: 37215 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: HERR HENRY D CENTRAL INDEX KEY: 0000903096 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 001-36531 FILM NUMBER: 161381573 MAIL ADDRESS: STREET 1: ONE BURTON HILLS BLVD CITY: NASHVILLE STATE: TN ZIP: 37215 5 1 wf-form5_145444992716084.xml FORM 5 X0306 5 2015-12-31 0 0 0 0000895930 AMSURG CORP AMSG 0000903096 HERR HENRY D 110 31ST AVE NORTH, UNIT 1003 NASHVILLE TN 37203 1 0 0 0 Common stock 107710 D 5.250% Mandatory Convertible Preferred Stock, Series A-1 2017-07-01 Common stock 400.0 400 D The Company's 5.250% mandatory convertible preferred stock, Series A-1 (the "Preferred Stock") will automatically convert on July 1, 2017. Holders of the Preferred Stock have the right to convert the Preferred Stock at any time prior to July 1, 2017 into shares of the Company's common stock. If the applicable market value of the Company's common stock is equal to or greater than $55.13, the fixed conversion rate will be 1.8141 shares of the Company's common stock per share of Preferred Stock, or a total of $725.64 shares of common stock. If the applicable market value of the Company's common stock is less than or equal to $45, the fixed conversion rate will be 2.2222 shares of the Company's common stock per share of Preferred Stock, or a total of 888.88 shares of common stock. If the applicable market value of the Company's common stock is more than $45.00 and less than $55.13, then the conversion rate will be equal to $100 divided by the applicable market value of the Company's stock. /s/ Henry D. Herr 2016-02-02