0001181431-11-048791.txt : 20110912 0001181431-11-048791.hdr.sgml : 20110912 20110912124538 ACCESSION NUMBER: 0001181431-11-048791 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20110908 FILED AS OF DATE: 20110912 DATE AS OF CHANGE: 20110912 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Kusumi Gary Y CENTRAL INDEX KEY: 0001441875 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-50795 FILM NUMBER: 111085268 MAIL ADDRESS: STREET 1: C/O AFFIRMATIVE INSURANCE HOLDINGS, INC. STREET 2: 150 HARVESTER DRIVE, SUITE 300 CITY: BURR RIDGE STATE: IL ZIP: 60527 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: AFFIRMATIVE INSURANCE HOLDINGS INC CENTRAL INDEX KEY: 0001282543 STANDARD INDUSTRIAL CLASSIFICATION: FIRE, MARINE & CASUALTY INSURANCE [6331] IRS NUMBER: 752770432 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 4450 SOJOURN DRIVE STREET 2: SUITE 500 CITY: ADDISON STATE: TX ZIP: 75001 BUSINESS PHONE: 972-728-6300 MAIL ADDRESS: STREET 1: 4450 SOJOURN DRIVE STREET 2: SUITE 500 CITY: ADDISON STATE: TX ZIP: 75001 4 1 rrd321759.xml FORM 4 X0304 4 2011-09-08 0 0001282543 AFFIRMATIVE INSURANCE HOLDINGS INC AFFM 0001441875 Kusumi Gary Y 150 HARVESTER DRIVE SUITE 300 BURR RIDGE IL 60527 1 1 0 0 Chairman & CEO Common Stock, $0.01 par value 2011-09-08 4 P 0 400 1.72 A 15000 D /s/ Gary Y. Kusumi 2011-09-12