EX-4 3 a2083350zex-4.txt EXHIBIT 4 EXHIBIT 4 [FRONT OF CERTIFICATE] COMMON STOCK COMMON STOCK SAFT THIS CERTIFICATE IS TRANSFERABLE IN CANTON, MA, JERSEY CITY, NJ AND NEW YORK, NY SEE REVERSE FOR CERTAIN DEFINITIONS SAFETY INSURANCE GROUP, INC. INCORPORATED UNDER THE LAWS OF THE STATE OF DELAWARE CUSIP 78648T 10 0 THIS CERTIFIES that is the owner of FULLY PAID AND NON-ASSESSABLE SHARES OF COMMON STOCK, PAR VALUE $.01 PER SHARE, OF SAFETY INSURANCE GROUP, INC., with principal offices in Boston, Massachusetts (the "Corporation"). The shares evidenced by this Certificate are transferable only on the books of the Corporation by the holder hereof, in person or by a duly authorized attorney or legal representative, upon surrender of this Certificate properly endorsed. This Certificate and the shares represented hereby are subject to all the provisions of the Certificate of Incorporation and Bylaws of the Corporation and any and all amendments thereto. The shares represented by this Certificate are not deposits or accounts and are not federally insured or guaranteed. This Certificate is not valid unless countersigned by the Transfer Agent and registered by the Registrar. IN WITNESS WHEREOF, the Corporation has caused this Certificate to be executed by the facsimile signatures of its duly authorized officers and has caused its facsimile seal to be affixed hereto. Dated: Chief Financial Officer and Secretary President and Chief Executive Officer Countersigned and Registered: EquiServe Trust Company, N.A. Transfer Agent and Registrar By Authorized SIGNATURE [BACK OF CERTIFICATE] The Corporation will furnish to any stockholder, upon written request and without charge, a full statement of the designations, preferences, limitations, and relative rights of the shares of each class authorized to be issued and, with respect to the issuance of any preferred stock to be issued in series, the relative rights, preferences and limitations between the shares of each series so far as the rights, preferences and limitations have been fixed and determined and the authority of the Board of Directors to fix and determine the relative rights, preferences and limitations of subsequent series. The Corporation is authorized to issue more than one class of stock, including a class of preferred stock, which may be issued in one or more series. The following abbreviations, when used in the inscription on the face of this Certificate, shall be construed as though they were written out in full according to applicable laws or regulations: TEN COM TEN ENT JT TEN as tenants in common as tenants by the entireties as joint tenants with right of survivorship and not as tenants in common UNIF GIFT MIN ACTD Custodian (Cust) (Minor) under Uniform Gifts to Minors Act (State) Additional abbreviations may also be used though not in the above list. For value received, hereby sell, assign and transfer unto PLEASE INSERT SOCIAL SECURITY OR OTHER TAXPAYER INDENTIFYING NUMBER OF ASSIGNEE (Please print or typewrite name and address including postal zip code of assignee) shares of Common Stock represented by this Certificate, and do hereby irrevocably constitute and appoint attorney-in-fact, to transfer the said shares on the books of the within named Corporation, with full power of substitution. Dated Signature Signature NOTICE: THE SIGNATURE(S) TO THIS ASSIGNMENT MUST CORRESPOND WITH THE NAME(S) AS WRITTEN UPON THE FACE OF THIS CERTIFICATE IN EVERY PARTICULAR, WITHOUT ALTERATION OR ENLARGEMENT, OR ANY CHANGE WHATEVER. Signature(s) Guaranteed: THE SIGNATURE(S) SHOULD BE GUARANTEED BY AN ELIGIBLE GUARANTOR INSTITUTION (BANKS, STOCKBROKERS, SAVINGS AND LOAN ASSOCIATIONS OR CREDIT UNIONS WITH MEMBERSHIP IN AN APPROVED SIGNATURE GUARANTEE MEDALLION PROGRAM), PURSUANT TO S.E.C. RULE 17Ad.15.