SEC Form 4 · accession 0001209191-16-119675
AMERISAFE INC · AMSF
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Vincent J. Gagliano
Officer — EVP - Chief Risk Officer
Period of report
May 10, 2016
Accepted (ET)
May 12, 2016 · 6:22 pm EDT
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001018979
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common stock, par value $0.01 | May 10, 2016 | M | 1,092 | $14.20 | A | 24,597 | D | |
| Common stock, par value $0.01F1 | May 10, 2016 | S | 1,092 | $57.06 | D | 23,505 | D | |
| Common stock, par value $0.01 | May 11, 2016 | M | 2,108 | $14.20 | A | 25,613 | D | |
| Common stock, par value $0.01F2 | May 11, 2016 | S | 2,108 | $57.17 | D | 23,505 | D |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Employee Stock Option (right to purchase)F3 | $14.20 | May 10, 2016 | M | 600 | D | Nov 9, 2012 | Nov 9, 2019 | Common stock | 600 | 7,600 | D |
| Employee Stock Option (right to purchase)F3 | $14.20 | May 10, 2016 | M | 492 | D | Nov 9, 2013 | Nov 9, 2019 | Common stock | 492 | 7,108 | D |
| Employee Stock Option (right to purchase)F3 | $14.20 | May 10, 2016 | M | 2,108 | D | Nov 9, 2013 | Nov 9, 2019 | Common stock | 2,108 | 5,000 | D |
Explanation of responses
- F1Represents the weighted average selling price of the Issuer's common stock. The range of sales prices were between $57.00 and $57.20. 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.
- F2Represents the weighted average selling price of the Issuer's common stock. The range of sales prices were between $57.00 and $57.24. 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.
- F3Represents stock options that become exercisable in five equal installments beginning on November 9, 2010, which was the first anniversary of the grant date. The options were exercised and sold pursuant to the Reporting Person's 10b5-1 plan.