4/A 1 l96610ee4za.htm BANCINSURANCE CORPORATION/JOHN S. SOKOL FORM 4 Bancinsurance Corporation/John S. Sokol Form 4
 

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UNITED STATES
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(h) of the Investment Company Act of 1940

o Check this box if no longer
subject to Section 16.
Form 4 or Form 5
obligations may continue.
See Instruction 1(b).

1. Name and Address of Reporting
Person*
(Last, First, Middle)
2. Issuer Name and Ticker or
Trading Symbol
3. I.R.S. Identification Number of Reporting
Person, if an entity
(Voluntary)
  Sokol, John S.
  Bancinsurance Corporation BCIS
 
  250 East Broad Street 10th Floor
4. Statement for Month/Day/Year 5. If Amendment, Date of Original (Month/Day/Year)
    August 30, 2002
  September 3, 2002
  (Street) 6. Relationship of Reporting Person(s)
to Issuer
(Check All Applicable)
7. Individual or Joint/Group Filing
(Check Applicable Line)
  Columbus, OH 43215
(City)                (State)           (Zip)
  x  Director o  10% Owner   x Form filed by One Reporting Person
    x  Officer (give title below)   o Form filed by More than One Reporting Person
    o  Other (specify below)  
        President
     

Reminder:   Report on a separate line for each class of securities beneficially owned directly or indirectly.
 
*   If the form is filed by more than one reporting person, see instruction 4(b)(v).
 

 


 


Table I — Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned

1. Title of Security
(Instr. 3)
2. Transaction Date
(Month/Day/Year)
2a. Deemed Execution
Date, if any.

(Month/Day/Year)
3. Transaction Code
(Instr. 8)
4. Securities Acquired (A)
or Disposed of (D)

(Instr. 3, 4 and 5)
5. Amount of Securities
Beneficially Owned
Following Reported
Transactions(s)

(Instr. 3 and 4)
6. Ownership
Form:
Direct (D) or
Indirect (I)

(Instr. 4)
7. Nature of
Indirect
Beneficial
Ownership

(Instr. 4)

              Code V   Amount (A)
or
(D)
Price            

  Common Shares   8/30/02   G(1) V   29,405   D          

  Common Shares   8/30/02     J(1)   150,000   D     69,206     I   By Trust (1)

  Common Shares   8/30/02     J(1)   1,750,000   A     1,750,000     I   By Falcon Equity Partners, L.P. (1)

  Common Shares   8/30/02     G(1)   29,405   A     76,535     D  

  Common Shares               2,100     I   (2)

  Common Shares               6,022     I   (3)

                     

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Table II — Derivative Securities Acquired, Disposed of, or Beneficially Owned
  (e.g., puts, calls, warrants, options, convertible securities)

1. Title of Derivative
Security

(Instr. 3)
2. Conversion or Exercise
Price of Derivative
Security
3. Transaction
Date

(Month/Day/Year)
3a. Deemed Execution
Date, if any

(Month/Day/Year)
4. Transaction
Code

(Instr. 8)
5. Number of Derivative Securities
Acquired (A) or Disposed of (D)

(Instr. 3, 4 and 5)

                      Code V   (A) (D)

             

             

             

             

             

             

             

             

             

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Table II — Derivative Securities Acquired, Disposed of, or Beneficially Owned — Continued
(e.g., puts, calls, warrants, options, convertible securities)

6. Date Exercisable and
Expiration Date

(Month/Day/Year)
7. Title and Amount
of Underlying Securities

(Instr. 3 and 4)
8. Price of Derivative
Security

(Instr. 5)
9. Number of Derivative
Securities Beneficially Owned
Following Reported Transaction(s)

(Instr. 4)
10. Ownership Form of
Derivative Security:
Direct (D) or Indirect (I)

(Instr. 4)
11. Nature of
Indirect
Beneficial
Ownership

(Instr. 4)

  Date
Exercisable
Expiration
Date
  Title Amount or
Number of
Shares
                       

                 

                 

                 

                 

                 

                 

                 

                 

                 

Explanation of Responses:

(1) John S. Sokol previously reported 248,611 BCIS common shares as being held in trust by Barbara K. Sokol, as trustee of a trust for the benefit of John S. Sokol. In accordance with the terms of the trust agreement, on August 30, 2002, Barbara K. Sokol, as trustee, distributed 29,405 BCIS common shares to John S. Sokol and transferred 150,000 BCIS common shares to Falcon Equity Partners, L.P. (“Falcon L.P.”), an Ohio limited partnership whose partners are members of the Simon Sokol family, on behalf of John S. Sokol. Falcon L.P. holds 1,750,000 BCIS common shares, and John S. Sokol holds an 8.6 percentage interest in Falcon L.P. John S. Sokol disclaims beneficial ownership of BCIS common shares shown as held by Falcon L.P., except to the extent of his pecuniary interest therein.

(2) These BCIS common shares are owned of record by John S. Sokol's wife, Elizabeth M. Sokol. John S. Sokol disclaims beneficial ownership of such BCIS common shares, and the filing of this report is not an admission that John S. Sokol is the beneficial owner of such BCIS common shares for the purpose of Section 16 or for any other purpose.

(3) These BCIS common shares are beneficially owned by John S. Sokol, as custodian for his minor daughter.

John S. Sokol    
/s/ Sally J. Cress as Attorney-in-Fact   10-9-2002

**Signature of Reporting Person
 
Date


**   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 is insufficient, see Instruction 6 for procedure.
 

Page 4


 

APPENDIX C

POWER OF ATTORNEY

     KNOW ALL MEN BY THESE PRESENTS: That the undersigned officer and/or director of Bancinsurance Corporation (the “Company”), hereby constitutes and appoints John S. Sokol and Sally J. Cress, and each of them, as his or her true and lawful attorneys-in-fact and agents, with full power of substitution and resubstitution, for him or her and in his or her name, place and stead, in any and all capacities, to sign any and all Forms 3, 4 and 5 that are required by Section 16(a) of the Securities Exchange Act of 1934, as amended, with respect to the securities of the Company beneficially owned by the undersigned, and any and all amendments thereto, and to file the same, and other documents relating thereto, with the Securities and Exchange Commission and any other applicable authority, and grants unto each of said attorneys-in-fact and substitute or substitutes full power and authority to do each and every act and thing requisite and necessary to be done in and about the premises, as fully to all intents and purposes as he or she might do in person, and hereby ratifies and confirms all things that each of said attorneys-in-fact and substitute or substitutes may lawfully do and seek to be done by virtue hereof.

     This Power of Attorney shall be valid until such time as it is revoked by the undersigned in writing.

     IN WITNESS WHEREOF, the undersigned has hereunto set his or her hand this 24th day of April, 1991.

  /s/ John S. Sokol

John S. Sokol