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OMB APPROVAL
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OMB Number: 3235-0362
Expires: January 31, 2005
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, DC 20549
FORM 5
ANNUAL 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
|X| Check box if no longer subject to Section 16. Form 4 or Form 5 obligations
may continue. See Instruction 1(b).
|_| Form 3 Holdings Reported
|_| Form 4 Transactions Reported
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1. Name and Address of Reporting Person*
Evason Kenneth L
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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. I.R.S. Identification Number of Reporting Person, if an entity (Voluntary)
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4. Statement for Month/Year
December, 2002
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5. If Amendment, Date of Original (Month/Year)
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6. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|_| Director |_| 10% Owner
|_| Officer (give title below) |X| Other (specify below)
Former Director
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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- 7.
Securities Acquired (A) Amount of ship Nature of
2. 2A. or Disposed of (D) Securities Form: Indirect
Trans- Deemed (Instr. 3, 4 and 5) Beneficially Direct Bene-
action Execution 3. Owned at end (D) or ficial
1. Date Date, If Transaction (A) of Issuer's Indirect Owner-
Title of Security (month/ any (month/ Code or Fiscal Year (I) ship
(Instr. 3) day/year) day/year) (Instr.8) Amount (D) Price (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).
FORM 5 (continued)
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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10.
9. Owner-
Number ship
2. of of
Conver- 5. 7. Deriv- Deriv- 11.
sion Number of Title and Amount ative ative Nature
or Derivative 6. of Underlying 8. Secur- Secur- of
Exer- 3A. Securities Date Securities Price ities ity: In-
cise Deemed Acquired (A) Exercisable and (Instr. 3 and 4) of Bene- Direct direct
Price 3. Execut- 4. or Disposed Expiration Date ---------------- Deriv- ficially (D) or Bene-
1. of Trans- ion Trans- of(D) (Month/Day/Year) Amount ative Owned In- ficial
Title of Deriv- action Date if action (Instr. 3, ---------------- or Secur- at End direct Owner-
Derivative ative Date any Code 4 and 5) Date Expira- Number ity of Year (I) ship
Security Secur- (mm/dd/ (mm/dd/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity yy) yy) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4)
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Non-Emp- $15.34 3/22/02 A 5,000 (1) 3/21/14 Common 5,000 5,000 D
loyee Stock (2) Stock (2)
Option (Right
to Buy)
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Explanation of Responses:
(1) Option vests in three (3) equal annual installments beginning 3/22/03.
(2) Pursuant to the terms of the stock option, the reported stock options were
cancelled for no value on 1/3/03 in connection with the reporting person's
resignation as a director of AMZ.
/s/ Cheryl A. Thomson 2/13/02
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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.
POWER OF ATTORNEY
Know all by these presents, that the undersigned hereby constitutes and
appoints each of Timothy J. Moore and Cheryl A. Thomson, signing singly, the
undersigned's true and lawful attorney-in-fact to:
(1) execute for and on behalf of the undersigned, in the
undersigned's capacity as an officer and/or director of the
Company, Forms 3, 4 and 5 in accordance with Section 16(a) of
the Securities Exchange Act of 1934 and the rules thereunder;
(2) do and perform any and all acts for and on behalf of the
undersigned which may be necessary or desirable to complete and
execute any such Form 3, 4 or 5 and timely file such form with
the United States Securities and Exchange Commission and any
stock exchange or similar authority; and
(3) take any other action of any type whatsoever in connection with
the foregoing which, in the opinion of such attorney-in-fact,
may be of benefit to, in the best interest of, or legally
required by, the undersigned, it being understood that the
documents executed by such attorney-in-fact on behalf of the
undersigned pursuant to this Power of Attorney shall be in such
form and shall contain such terms and conditions as such
attorney-in-fact may approve in such attorney-in-fact's
discretion.
The undersigned hereby grants to each such attorney-in-fact full power
and authority to do and perform any and every act and thing whatsoever
requisite, necessary, or proper to be done in the exercise of any of the rights
and powers herein granted, as fully to all intents and purposes as the
undersigned might or could do if personally present, with full power of
substitution or revocation, hereby ratifying and confirming all that such
attorney-in-fact's substitute or substitutes, shall lawfully do or cause to be
done by virtue of this power of attorney and the rights and powers herein
granted. The undersigned acknowledges that the foregoing attorneys-in-fact, in
serving in such capacity at the request of the undersigned, are not assuming,
nor is the Company assuming, any of the undersigned's responsibilities to comply
with Section 16 of the Securities Exchange Act of 1934.
This Power of Attorney shall remain in full force and effect until the
undersigned is no longer required to file Forms 3, 4 and 5 with respect to the
undersigned's holdings of and transactions in securities issued by the Company,
unless earlier revoked by the undersigned in a signed writing delivered to the
foregoing attorneys-in-fact.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to
be executed as of this 28th day of March, 2002.
/s/ Ken L. Evason
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Kenneth L. Evason Signature
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