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U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, DC 20549
FORM 4
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(f) of the Investment Company Act of 1940
[_] Check box if no longer subject to Section 16. Form 4 or Form 5 obligations
may continue. See Instruction 1(b).
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1. Name and Address of Reporting Person*
Zielinski Thomas G
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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. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
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4. Statement for Month/Day/Year
01/20/03
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5. If Amendment, Date of Original (Month/Day/Year)
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6. Relationship of Reporting Person to Issuer
(Check all applicable)
[_] Director [_] 10% Owner
[x] Officer (give title below) [_] Other (specify below)
Executive Vice President of Operations
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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-
Securities Acquired (A) or Amount of ship
3. Disposed of (D) Securities Form: 7.
2A. Transaction (Instr. 3, 4 and 5) Beneficially Direct Nature of
2. Deemed Exec- Code ------------------------------- Owned Follow- (D) or Indirect
1. Transaction ution Date, (Instr. 8) (A) ing Reported Indirect Beneficial
Title of Security Date if any ------------ Amount or Price Transactions (I) Ownership
(Instr. 3) (mm/dd/yy) (mm/dd/yy) Code V (D) (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).
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
(Print or Type Response) (Over)
FORM 4 (continued)
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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9. 10.
Number Owner-
of ship
Deriv- Form
2. ative of
Conv- 5. 7. Secur- Deriv- 11.
ersion Number of Title and Amount ities ative Nature
or Derivative 6. of Underlying 8. Bene- Secur- of
Exer- 3A. 4. Securities Date Securities Price ficially ity: In-
cise 3. Deemed Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of Owned Direct direct
1. Price Trans- Exec- action or Disposed Expiration Date ---------------- Deriv- Follow- (D) or Bene-
Title of of action ution Code of(D) (Month/Day/Year) Amount ative ing Rep- In- ficial
Deriv- Deriv- Date Date, (Instr. (Instr. 3, ---------------- or Secur- orted direct Owner-
ative Sec- ative (Month/ if any 8) 4 and 5) Date Expira- Number ity Trans- (I) ship
urity Secur- Day/ (mm/dd ------ ------------ Exer- tion of (Instr. action(s) (Instr. (Instr.
(Instr.3) ity Year) /yy) Code V (A) (D) cisable Date Title Shares 5) (Instr.4) 4) 4)
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Employee $14.41 01/20/03 A 42,500 (1) 01/19/15 Common 42,500 42,500 D
Stock Stock
Option
(Right to
Buy)
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Explanation of Responses:
(1) Option vests in four (4) equal annual installments beginning 1/20/2004.
/s/ Cheryl A. Thomson 1/22/03
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**Signature of Reporting Person Date
Attorney-in-Fact
[Power of Attorney is attached]
** 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.
Potential persons who are to respond to the collection of information contained
in this form are not required to respond unless the form displays a currently
valid OMB Number.
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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 American
Medical Security Group, Inc. (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 3rd day of August, 1999.
/s/ Thomas G. Zielinski
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Thomas G. Zielinski Signature
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