-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, ORp0xz7CxsOiBd9+KhyovUmNEynlRG3kyC97agBH0gEH2L5QCYs2Ni2h7QnT11+f TbX2ZN1MEQNCANcYosYmMQ== 0000892712-00-000041.txt : 20000215 0000892712-00-000041.hdr.sgml : 20000215 ACCESSION NUMBER: 0000892712-00-000041 CONFORMED SUBMISSION TYPE: SC 13G/A PUBLIC DOCUMENT COUNT: 1 FILED AS OF DATE: 20000214 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: AMERICAN MEDICAL SECURITY GROUP INC CENTRAL INDEX KEY: 0000878897 STANDARD INDUSTRIAL CLASSIFICATION: HOSPITAL & MEDICAL SERVICE PLANS [6324] IRS NUMBER: 391431799 STATE OF INCORPORATION: WI FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: SC 13G/A SEC ACT: SEC FILE NUMBER: 005-41965 FILM NUMBER: 542605 BUSINESS ADDRESS: STREET 1: 3100 AMS BLVD CITY: GREEN BAY STATE: WI ZIP: 54313 BUSINESS PHONE: 9206611111 MAIL ADDRESS: STREET 1: 3100 AMS BLVD CITY: GREEN BAY STATE: WI ZIP: 54313 FORMER COMPANY: FORMER CONFORMED NAME: UNITED WISCONSIN SERVICES INC /WI DATE OF NAME CHANGE: 19930328 FILED BY: COMPANY DATA: COMPANY CONFORMED NAME: HILLIARD WALLACE J CENTRAL INDEX KEY: 0001026646 STANDARD INDUSTRIAL CLASSIFICATION: [] FILING VALUES: FORM TYPE: SC 13G/A BUSINESS ADDRESS: STREET 1: 4161 NW 5TH STREET CITY: PLANTATION STATE: FL ZIP: 33317 BUSINESS PHONE: 9545819993 MAIL ADDRESS: STREET 1: 4161 NW 5TH STREET CITY: PLANTATION STATE: FL ZIP: 33317 SC 13G/A 1 AMENDMENT NO. 4 TO SCHEDULE 13G United States Securities and Exchange Commission Washington, D.C. 20549 Schedule 13G Under the Securities Exchange Act of 1934 (Amendment No. 4) American Medical Security Group, Inc. --------------------------------------- (Name of Issuer) Common Stock, no par value --------------------------------------- (Title of Class of Securities) 913236105 --------------------------------------- (CUSIP Number) December 31, 1999 --------------------------------------- (Date of Event Which Requires Filing of this Amendment) Check the appropriate box to designate the rule pursuant to which this Schedule is filed: [ ] Rule 13d-1(b) [ ] Rule 13d-1(c) [X] Rule 13d-1(d) * The remainder of this cover page shall be filled out for a reporting person's initial filing on this form with respect to the subject class of securities, and for any subsequent amendment containing information which would alter the disclosures provided in a prior cover page. The information required in the remainder of this cover page shall not be deemed to be "filed" for the purpose of Section 18 of the Securities Exchange Act of 1934 ("Act") or otherwise subject to the liabilities of that section of the Act but shall be subject to all other provisions of the Act. Schedule 13G CUSIP No. 913236105 1. NAME OF REPORTING PERSON. Wallace J. Hilliard S.S. or IRS IDENTIFICATION NO. OF ABOVE PERSON. ###-##-#### 2. CHECK THE APPROPRIATE BOX IF A MEMBER OF A GROUP. (a) [ ] (b) [ ] 3. SEC USE ONLY. 4. CITIZENSHIP OR PLACE OF ORGANIZATION. USA NUMBER OF SHARES BENEFICIALLY OWNED BY EACH REPORTING PERSON WITH: 5. SOLE VOTING POWER. Not applicable 6. SHARED VOTING POWER. Not applicable 7. SOLE DISPOSITIVE POWER. Not applicable 8. SHARED DISPOSITIVE POWER. Not applicable 9. AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH REPORTING PERSON. Not applicable 10. CHECK IF THE AGGREGATE AMOUNT IN ROW (9) EXCLUDES CERTAIN SHARES. 11. PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW (9). Not applicable 12 TYPE OF REPORTING PERSON. IN Schedule 13G CUSIP No. 913236105 ITEM 1(a). NAME OF ISSUER American Medical Security Group, Inc. ITEM 1(b). ADDRESS OF ISSUER'S PRINCIPAL EXECUTIVE OFFICES. 3100 AMS Boulevard Green Bay, Wisconsin 54313 ITEM 2(a). NAME OF PERSON FILING Wallace J. Hilliard ITEM 2(b). ADDRESS OF PRINCIPAL BUSINESS OFFICE, OR, IF NONE, RESIDENCE P.O. Box 12146 Green Bay, Wisconsin 54307-2146 ITEM 2(c). CITIZENSHIP U.S.A ITEM 2(d). TITLE OR CLASS OF SECURITIES Common Stock, no par value ITEM 2(e). CUSIP NUMBER 913236105 ITEM 3. N/A ITEM 4. OWNERSHIP (a) Amount Beneficially Owned: Not applicable (b) Percent of Class: Not applicable (c) Number of Shares as to which such person has: (i) sole power to vote or to direct the vote: Not applicable (ii) shared power to vote or to direct the vote: Not applicable (iii) sole power to dispose or to direct the disposition of: Not applicable (iv) shared power to dispose or to direct the disposition of: Not applicable ITEM 5. OWNERSHIP OF FIVE PERCENT OR LESS OF A CLASS If this statement is being filed to report the fact that as of the date hereof the reporting person has ceased to be the beneficial owner of more than five percent of the class of securities, check the following [X]. ITEM 6. OWNERSHIP OF MORE THAN FIVE PERCENT ON BEHALF OF ANOTHER PERSON. N/A ITEM 7. IDENTIFICATION AND CLASSIFICATION OF THE SUBSIDIARY WHICH ACQUIRED THE SECURITY BEING REPORTED ON BY THE PARENT HOLDING COMPANY. N/A ITEM 8. IDENTIFICATION AND CLASSIFICATION OF MEMBERS OF THE GROUP. N/A ITEM 9. NOTICE OF DISSOLUTION OF GROUP. N/A ITEM 10. CERTIFICATION N/A After reasonable inquiry and to the best of my knowledge and belief, I certify that the information set forth in this statement is true, complete and correct. Dated as of the 14th day of February, 2000. /s/ Wallace J. Hilliard --------------------------- (Signature) Wallace J. Hilliard -----END PRIVACY-ENHANCED MESSAGE-----