-----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, TLvmeHU532AqGKhj9xLZBNIOJePs6i9h0bAd2CG0W/+uZv2jqde7Tzm854QTyI3+ 5loE7UvPEmGmzc86eXIq1w== 0000950152-98-008615.txt : 19981109 0000950152-98-008615.hdr.sgml : 19981109 ACCESSION NUMBER: 0000950152-98-008615 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 19981001 FILED AS OF DATE: 19981106 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: ALLIED LIFE FINANCIAL CORP CENTRAL INDEX KEY: 0000912154 STANDARD INDUSTRIAL CLASSIFICATION: LIFE INSURANCE [6311] IRS NUMBER: 421406716 STATE OF INCORPORATION: IA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: SEC FILE NUMBER: 000-22404 FILM NUMBER: 98739670 BUSINESS ADDRESS: STREET 1: 701 FIFTH AVE CITY: DES MOINES STATE: IA ZIP: 50391-2003 BUSINESS PHONE: 5152804211 MAIL ADDRESS: STREET 1: 701 FIFTH AVENUE CITY: DES MOINES STATE: IA ZIP: 50391-2003 COMPANY DATA: COMPANY CONFORMED NAME: NATIONWIDE MUTUAL INSURANCE CO CENTRAL INDEX KEY: 0000315099 STANDARD INDUSTRIAL CLASSIFICATION: [] OWNER STATE OF INCORPORATION: OH FILING VALUES: FORM TYPE: 3 BUSINESS ADDRESS: STREET 1: ONE NATIONWIDE ENTERPRISE CITY: COLUMBUS STATE: OH ZIP: 43125 BUSINESS PHONE: 6142497111 MAIL ADDRESS: STREET 1: ONE NATIONWIDE ENTERPRISE CITY: COLUMBUS STATE: OH ZIP: 43215 3 1 ALLIED LIFE/NATIONWIDE MUTUAL INSURANCE FORM 3 1
-------------------------- FORM 3 OMB Approval U.S. SECURITIES AND EXCHANGE COMMISSION -------------------------- WASHINGTON, D.C. 20549 OMB Number 3235-0104 Expires: September 30, 1998 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Estimated average burden hours per response... 0.5 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 - ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting | 2. Date of Event Re- | 4. Issuer Name AND Ticker or Trading Symbol Person* | quiring Statement | ALLIED Life Financial Corporation (ALFC) Nationwide Life Acquisition Corporation| (Month/Day/Year) |------------------------------------------------------------------ - ---------------------------------------| | 5. Relationship of Reporting | 6. If Amendment, Date of (Last) (First) (Middle) | 10/1/98 | Person(s) to Issuer | Original (Month/Day/Year) |-------------------------| (Check all applicable) | One Nationwide Plaza | 3. IRS or Social | ___ Director __X__ 10% Owner|------------------------------- - ---------------------------------------| Security Number | ___ Officer _____ Other | 7. Ind.or Joint/Group Filing (Street) | of Reporting | (give title (specify | Form filed by: | Person (Voluntary) | below below) | ___ One Reporting Person | | | _X_ More than One Reporting Columbus Ohio 43215 | 31-1618317 | ------------------------ | Person - ------------------------------------------------------------------------------------------------------------------------------------ (City) (State) (Zip) | TABLE I - NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED | - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security | 2. Amount of Securities | 3. Ownership | 4. Nature of Indirect Beneficial (Instr. 4) | Beneficially Owned | Form: Direct | Ownership (Instr. 5) | (Instr. 4) | (D) or Indirect | | | (I) (Instr. 5) | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- Common Stock | 4,519,033 | D | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- 6.75% Series Preferred Stock | 2,410,098 | D | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- | | | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- | | | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- | | | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- | | | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- | | | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- | | | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- | | | - ------------------------------------------------------------------------------------------------------------------------------------ Reminder: Report on a separate line for each class of securities beneficially owned, directly or indirectly. (Over) * If the form is filed by more than one reporting person, see Instruction 5(b)(v) SEC 1473 (7-96)
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FORM 3 (CONTINUED) TABLE II - DERIVATIVE SECURITIES BENEFICIALLY OWNED (E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES) - ------------------------------------------------------------------------------------------------------------------------------------ 1.Title of Derivative Security | 2.Date Exer- | 3.Title and Amount of Securities | 4.Conver- | 5. Owner- | 6. Nature of Indirect (Instr. 4) | cisable and | Underlying Derivative Security | sion or | ship | Beneficial | Expiration | (Instr. 4) | Exercise | Form of | Ownership | Date | | Price of | Deriv- | (Instr. 5) | (Month/Day/ | | Deriv- | ative | | Year) | | ative | Security:| |---------------|----------------------------------| Security | Direct | |Date | Expir-| | Amount | | (D) or | |Exer- | ation | Title | or | | Indirect | |cisable| Date | | Number | | (I) | | | | | of | | (Instr. 5) | | | | | Shares | | | - -------------------------------|-------|-------|-------------------------|--------|-----------|-------------|----------------------- | | | | | | | - -------------------------------|-------|-------|-------------------------|--------|-----------|-------------|----------------------- | | | | | | | - -------------------------------|-------|-------|-------------------------|--------|-----------|-------------|----------------------- | | | | | | | - -------------------------------|-------|-------|-------------------------|--------|-----------|-------------|----------------------- | | | | | | | - -------------------------------|-------|-------|-------------------------|--------|-----------|-------------|----------------------- | | | | | | | - -------------------------------|-------|-------|-------------------------|--------|-----------|-------------|----------------------- | | | | | | | - -------------------------------|-------|-------|-------------------------|--------|-----------|-------------|----------------------- | | | | | | | - -------------------------------|-------|-------|-------------------------|--------|-----------|-------------|----------------------- | | | | | | | - -------------------------------|-------|-------|-------------------------|--------|-----------|-------------|----------------------- | | | | | | | - -------------------------------|-------|-------|-------------------------|--------|-----------|-------------|----------------------- | | | | | | | - ------------------------------------------------------------------------------------------------------------------------------------ Explanation of Responses: NATIONWIDE LIFE ACQUISITION CORPORATION By: /s/ Mark B. Koogler 11/6/98 ------------------------------------ ----------------- *Signature of Reporting Person Date Name: Mark B. Koogler Title: Vice President-Associate General Counsel NATIONWIDE MUTUAL INSURANCE COMPANY By: /s/ David A. Diamond 11/6/98 ------------------------------------ ----------------- *Signature of Reporting Person Date Name: David A. Diamond Title: Vice President-Enterprise Controller ** 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 currently valid OMB Number. Page 2 SEC 1473 (7-96)
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-------------------------- FORM 3 OMB Approval U.S. SECURITIES AND EXCHANGE COMMISSION -------------------------- WASHINGTON, D.C. 20549 OMB Number 3235-0104 Expires: September 30, 1998 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES Estimated average burden hours per response... 0.5 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 - ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting | 2. Date of Event Re- | 4. Issuer Name AND Ticker or Trading Symbol Person* | quiring Statement | ALLIED Life Financial Corporation (ALFC) Nationwide Mutual Insurance Company | (Month/Day/Year) |------------------------------------------------------------------ - ---------------------------------------| | 5. Relationship of Reporting | 6. If Amendment, Date of (Last) (First) (Middle) | 10/1/98 | Person(s) to Issuer | Original (Month/Day/Year) |-------------------------| (Check all applicable) | One Nationwide Plaza | 3. IRS or Social | ___ Director _____ 10% Owner|------------------------------- - ---------------------------------------| Security Number | ___ Officer _____ Other | 7. Ind.or Joint/Group Filing (Street) | of Reporting | (give title (specify | Form filed by: | Person (Voluntary) | below below) | ___ One Reporting Person | | | ___ More than One Reporting Columbus Ohio 43215 | 31-4177100 | ------------------------ | Person - ------------------------------------------------------------------------------------------------------------------------------------ (City) (State) (Zip) | TABLE I - NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED | - ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security | 2. Amount of Securities | 3. Ownership | 4. Nature of Indirect Beneficial (Instr. 4) | Beneficially Owned | Form: Direct | Ownership (Instr. 5) | (Instr. 4) | (D) or Indirect | | | (I) (Instr. 5) | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- | | | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- | | | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- | | | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- | | | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- | | | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- | | | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- | | | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- | | | - ---------------------------------------|---------------------------------|----------------------|----------------------------------- | | | - ------------------------------------------------------------------------------------------------------------------------------------ Reminder: Report on a separate line for each class of securities beneficially owned, directly or indirectly. (Over) * If the form is filed by more than one reporting person, see Instruction 5(b)(v) SEC 1473 (7-96)
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