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OMB APPROVAL
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OMB Number: 3235-0287
Expires: January 31, 2005
Estimated average burden
hours per response.... 0.5
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U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, DC 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(f) of the Investment Company Act of 1940
[_] Check box if no longer subject to Section 16. Form 4 or Form 5 obligations
may continue. See Instruction 1(b).
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1. Name and Address of Reporting Person*
Ballou Roger H.
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(Last) (First) (Middle)
3100 AMS Boulevard
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(Street)
Green Bay WI 54313
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
American Medical Security Group, Inc. (AMZ)
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3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
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4. Statement for Month/Day/Year
1/20/2003
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5. If Amendment, Date of Original (Month/Day/Year)
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6. Relationship of Reporting Person to Issuer
(Check all applicable)
[x] Director [_] 10% Owner
[_] Officer (give title below) [_] Other (specify below)
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7. Individual or Joint/Group Filing (Check applicable line)
[x] Form filed by one Reporting Person
[_] Form filed by more than one Reporting Person
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Table I -- Non-Derivative Securities Acquired, Disposed of,
or Beneficially Owned
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6.
4. 5. Owner-
Securities Acquired (A) or Amount of ship
3. Disposed of (D) Securities Form: 7.
2A. Transaction (Instr. 3, 4 and 5) Beneficially Direct Nature of
2. Deemed Exec- Code ------------------------------- Owned Follow- (D) or Indirect
1. Transaction ution Date, (Instr. 8) (A) ing Reported Indirect Beneficial
Title of Security Date if any ------------ Amount or Price Transactions (I) Ownership
(Instr. 3) (mm/dd/yy) (mm/dd/yy) Code V (D) (Instr.3 & 4) (Instr.4) (Instr. 4)
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* If the Form is filed by more than one Reporting Person, see Instruction
4(b)(v).
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
(Print or Type Response) (Over)
FORM 4 (continued)
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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9. 10.
Number Owner-
of ship
Deriv- Form
2. ative of
Conv- 5. 7. Secur- Deriv- 11.
ersion Number of Title and Amount ities ative Nature
or Derivative 6. of Underlying 8. Bene- Secur- of
Exer- 3A. 4. Securities Date Securities Price ficially ity: In-
cise 3. Deemed Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of Owned Direct direct
1. Price Trans- Exec- action or Disposed Expiration Date ---------------- Deriv- Follow- (D) or Bene-
Title of of action ution Code of(D) (Month/Day/Year) Amount ative ing Rep- In- ficial
Deriv- Deriv- Date Date, (Instr. (Instr. 3, ---------------- or Secur- orted direct Owner-
ative Sec- ative (Month/ if any 8) 4 and 5) Date Expira- Number ity Trans- (I) ship
urity Secur- Day/ (mm/dd ------ ------------ Exer- tion of (Instr. action(s) (Instr. (Instr.
(Instr.3) ity Year) /yy) Code V (A) (D) cisable Date Title Shares 5) (Instr.4) 4) 4)
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Non-empl- $14.41 1/20/03 A 6,700 (1) 1/19/15 Common 6,700 6,700 D
oyee Dir- Stock
ector Stock
Option (Right
to Buy)
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Explanation of Responses:
(1) Option vests in three (3) equal annual installments beginning 1/20/2004.
/s/ Cheryl A. Thomson 1/22/03
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**Signature of Reporting Person Date
Attorney-in-Fact
** Intentional misstatements or omissions of facts constitute Federal
Criminal Violations.
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
Note: File three copies of this Form, one of which must be manually signed.
If space provided 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.
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