SEC Form 4 · accession 0001060435-16-000003
AMERICAN INDEPENDENCE CORP · AMIC
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Ronald I Simon
Director
Period of report
Aug 31, 2016
Accepted (ET)
Sep 1, 2016 · 5:15 pm EDT
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0000097196
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common StockF1 | Aug 31, 2016 | J | 16,668 | — | D | 0 | 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 buy)F2 | $7.01 | Aug 31, 2016 | J | 1,111 | D | — | Jun 12, 2023 | Common Stock | 1,111 | 0 | D |
Explanation of responses
- F1Disposed of pursuant to the merger of the Issuer with and into AMIC Holdings, Inc. (the "Merger") in exchange for $24.74 per share.
- F2This option was canceled in connection with the Merger; in consideration thereof, the Reporting Person received the right to receive $24.74 per share of Common Stock underlying the option, less the exercise price of the option.