4 1 0001.txt UNITED STATES SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 FORM 4 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP ( ) Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instructions 1(b). 1. Name and Address of Reporting Person: John A. Dore 222 N. LaSalle St., Suite 1600 Chicago, Illinois 60601 U.S.A. 2. Issuer Name and Ticker or Trading Symbol: American Country Holdings Inc. ACHI 3. IRS or Social Security Number of Reporting Person (Voluntary): 4. Statement for Month/Year: September 2000 5. If Amendment, Date of Original (Month/Year): September 2000 6. Relationship of Reporting Person(s) to Issuer (Check all applicable): (x) Director ( ) 10% Owner (x) Officer (give title below) ( ) Other (specify below): Co-Chairman of the Board, Director and Chief Executive Officer 7. Individual or Joint/Group Filing (Check Applicable Line): (x) Form filed by One Reporting Person ( ) Form filed by More than One Reporting Person
Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned 5. Amount of 2. Trans- Securities 6. Owner- action 3. Trans- Beneficially ship Form: 1. Title of Date action 4. Securities Acquired Owned at End Direct (D) or 7. Nature of Indirect Security (Month/ Code (A) or Disposed of (D) of Month Indirect (I) Beneficial Ownership (Instr. 3) Day/Year) (Instr. 8) (Instr. 3, 4 and 5) (Instr. 3 and 4) (Instr. 4) (Instr. 4) ----------- --------- ---------- ---------------------- ---------------- ------------- --------------------- Code V Amount (A)or(D) Price ---- - ------ -------- ----- Common Stock, 9/25/00 C 100,000 A $2.88 161,000 D $.01 par value Common Stock, 2,000 I IRA $.01 par value Common Stock, 4,000 I Keogh $.01 par value Common Stock, 2,600 I As trustee for $.01 par value Christopher L. Dore Common Stock, 3,565 I As trustee for John A. $.01 par value Dore II
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) 10. 9. Owner- 5. Number ship Number of Deri- Form of 2. of Deriv- vative Deri- 11. Conver- ative Securi- vative Nature sion or Secur- ties Secur- of Indi- 1. Exer- 3. ities 7. 8. Benefi- ity: rect Title of cise Trans- Acquired 6. Title and Price cially Direct Benefi- Deriv- Price action 4. (A) or Date Exer- Amount of of Deriv- Owned at (D) or cial ative of Date Trans- Disposed cisable and Underlying ative End of Indirect Owner- Security Deriv- (Month/ action of (D) Expiration Securities Security Month (I) ship (Instr. ative Day/ Code (Instr. 3, Date(Month/ (Instr. 3 (Instr. (Instr. (Instr. (Instr. 3) Security Year) (Instr. 8) 4 and 5) Day/Year) and 4) 5) 4) 4) 4) -------- -------- ------- ---------- ---------- ------------- ----------- -------- -------- -------- -------- Date Expir- Amount or Exer- ation Number of Code V (A) (D) cisable Date Title Shares ---- - --- --- ------- ------ ----- --------- Option 2.88 9/25/00 C D 100,000 Common 100,000 Stock Option 2.88 8/17/03* 8/16/10 Common 300,000 2.88 300,000 D Stock
Explanation of Responses: * The 300,00 options held by Mr. Dore vest of 33 1/3% per year and were fully exercisable three years after date of grant. SIGNATURE OF REPORTING PERSON: /s/ John A. Dore ============================== Dated: October 3, 2000