Statement of Changes in Beneficial Ownership (4)
24 May 2022 - 08:06AM
Edgar (US Regulatory)
FORM 4
[ ] Check this box if no longer subject to Section
16. Form 4 or Form 5 obligations may continue. See
Instruction 1(b).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL
OWNERSHIP OF SECURITIES
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OMB
APPROVAL
OMB Number: 3235-0287
Estimated average burden
hours per response... 0.5 |
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Filed pursuant to Section 16(a) of the
Securities Exchange Act of 1934 or Section 30(h) of the Investment
Company Act of 1940
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1. Name
and Address of Reporting Person * Shirley Kathryn
Housh |
2. Issuer Name and Ticker or Trading
Symbol AMERISAFE INC [ AMSF ] |
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)_____
Director _____
10% Owner
__X__ Officer (give title
below) _____ Other
(specify below)
EVP - CAO |
(Last)
(First)
(Middle)
2301 HIGHWAY 190 WEST |
3. Date of Earliest Transaction (MM/DD/YYYY)
5/19/2022
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(Street)
DERIDDER, LA 70634
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line) _X _ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person |
Table I - Non-Derivative Securities Acquired, Disposed of, or
Beneficially Owned
|
1.Title of Security
(Instr. 3) |
2. Trans. Date |
2A. Deemed Execution Date, if any |
3. Trans. Code
(Instr. 8) |
4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5) |
5. Amount of Securities Beneficially Owned Following
Reported Transaction(s)
(Instr. 3 and 4) |
6. Ownership Form: Direct (D) or Indirect (I)
(Instr. 4) |
7. Nature of Indirect Beneficial Ownership (Instr.
4) |
Code |
V |
Amount |
(A) or (D) |
Price |
Common stock, par value
$0.01 |
5/19/2022 |
|
A |
|
4554 (1) |
A |
$0.00 |
16117 |
D |
|
Common stock, par value
$0.01 |
5/23/2022 |
|
S |
|
2277 (2) |
D |
$48.31 (3) |
13840 |
D |
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Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible
securities)
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1. Title of Derivate Security
(Instr. 3) |
2. Conversion or Exercise Price of Derivative
Security |
3. Trans. Date |
3A. Deemed Execution Date, if any |
4. Trans. Code
(Instr. 8) |
5. Number of Derivative Securities Acquired (A) or
Disposed of (D)
(Instr. 3, 4 and 5) |
6. Date Exercisable and Expiration Date |
7. Title and Amount of Securities Underlying
Derivative Security
(Instr. 3 and 4) |
8. Price of Derivative Security
(Instr. 5) |
9. Number of derivative Securities Beneficially
Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct
(D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr.
4) |
Code |
V |
(A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
Explanation of
Responses: |
(1) |
Shares issued for the
2019-2021 performance period under an award agreement between the
reporting person and the Company pursuant to the Company's Equity
and Incentive Compensation Plan. The awards were determined by the
Compensation Committee of the Board of Directors of the Company on
May 19, 2022 in accordance with the terms of the Plan and the
related award agreement. |
(2) |
The shares were sold
pursuant to the Reporting Person's 10b5-1 plan primarily to pay
required withholding taxes associated with the shares awarded under
the related award agreement. |
(3) |
Represents the weighted
average selling price of the Issuer's common stock. The range of
sales prices were between $48.05 and $48.81. The Reporting Person
undertakes, upon request, to provide the SEC, the Issuer and any
security holder of the Issuer, full information regarding the
number of shares sold at each separate price. |
Reporting
Owners
|
Reporting Owner Name / Address |
Relationships
|
Director |
10% Owner |
Officer |
Other |
Shirley Kathryn Housh
2301 HIGHWAY 190 WEST
DERIDDER, LA 70634 |
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|
EVP - CAO |
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Signatures
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/s/Kathryn H. Shirley |
|
5/23/2022 |
**Signature of Reporting
Person |
Date |
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). |
** |
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 is insufficient, see
Instruction 6 for procedure. |
Persons who respond to the collection of information
contained in this form are not required to respond unless the form
displays a currently valid OMB control number. |
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