SEC Form 4 · accession 0001209191-16-139328

AMERISAFE INC · AMSF

Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗

Reporting owner

Officer — President & CEO

Period of report

Aug 29, 2016

Accepted (ET)

Aug 31, 2016 · 5:10 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
Common stock, par value $0.01	Aug 29, 2016	A	10,000	$0.00	A	60,321	D
Common stock, par value $0.01^F1	Aug 29, 2016	S	7,568	$59.19	D	52,753	D
Common stock, par value $0.01	Aug 30, 2016	A	20,000	$0.00	A	72,753	D
Common stock, par value $0.01^F2	Aug 30, 2016	S	15,432	$59.01	D	57,321	D

Security	Conv. / exercise price	Date	Code	Shares	A/D	Exercisable	Expires	Underlying	Underlying shares	Owned after	D/I
Employee Stock Option (right to purchase)	$11.21	Aug 29, 2016	M	10,000	D	Nov 10, 2013	Nov 10, 2018	Common Stock	10,000	35,000	D
Employee Stock Option (right to purchase	$11.21	Aug 30, 2016	M	20,000	D	Nov 10, 2013	Nov 10, 2018	Common Stock	20,000	15,000	D

F1Represents the weighted average selling price of the Issuer's common stock. The range of sales prices were between $59.02 and $59.30. 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 $58.61 and $59.24. 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.