-----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, JXDguJXhkBfkG6SkkktIwOknS48bA8pHL/DCIDcj2RrS7eczaCz8ZRJaOklfIgYU Ipk6H8hLA1O6sMtAUYpYoA== 0000895813-01-000015.txt : 20010123 0000895813-01-000015.hdr.sgml : 20010123 ACCESSION NUMBER: 0000895813-01-000015 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20001231 FILED AS OF DATE: 20010110 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: AMERICAN COUNTRY HOLDINGS INC CENTRAL INDEX KEY: 0000315411 STANDARD INDUSTRIAL CLASSIFICATION: FIRE, MARINE & CASUALTY INSURANCE [6331] IRS NUMBER: 060995978 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: SEC FILE NUMBER: 000-22922 FILM NUMBER: 1506594 BUSINESS ADDRESS: STREET 1: 222 N LASALLE STREET STREET 2: C/O JOHN DE ELORZA CITY: CHICAGO STATE: IL ZIP: 60601-1105 BUSINESS PHONE: 3124562000 MAIL ADDRESS: STREET 1: 222 N LASALLE STREET CITY: CHICAGO STATE: IL ZIP: 60601-1105 FORMER COMPANY: FORMER CONFORMED NAME: WESTERN SYSTEMS CORP DATE OF NAME CHANGE: 19970326 FORMER COMPANY: FORMER CONFORMED NAME: WESTERN TRANSMEDIA CO INC DATE OF NAME CHANGE: 19920703 FORMER COMPANY: FORMER CONFORMED NAME: VIGILANCE SYSTEMS CORP DATE OF NAME CHANGE: 19920202 COMPANY DATA: COMPANY CONFORMED NAME: DORE JOHN A CENTRAL INDEX KEY: 0000938466 STANDARD INDUSTRIAL CLASSIFICATION: [] DIRECTOR FILING VALUES: FORM TYPE: 4 BUSINESS ADDRESS: STREET 1: AMERICAN COUNTRY HOLDINGS INC STREET 2: 222 N LASALLE ST STE 1600 CITY: CHICAGO STATE: IL ZIP: 60601 BUSINESS PHONE: 3124563745 MAIL ADDRESS: STREET 1: AMERICAN COUNTRY HOLDINGS INC STREET 2: 222 N LASALLE ST STE 1600 CITY: CHICAGO STATE: IL ZIP: 60601 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, 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: December 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): 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 12/29/00 P 142,857 A $1.75 D Stock, $.01 par value(1) Common 12/30/00 A 7,407 A $1.88 311,264(2) D Stock, $.01 par value Common 2,000 I IRA Stock, $.01 par value Common 4,000 I Keough Stock, $.01 par value Common 2,600 I As trustee for Stock, Christopher L. Dore $.01 par value Common 3,565 12,165 I As trustee for Stock, John A. Dore II $.01 par value (1) Each share of Common Stock was sold as a Unit that consisted of one share of Common Stock of the Company and five-year Common Stock purchase Warrant. The purchase price of each Unit was $1.75, and the Warrant exercise price is $1.925, subject to adjustment. (2) Includes 7,407 shares acquired under the employee stock purchase plan in December 2000.
. Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
10. 9. Owner- 5. Number ship 2. Number of Deri- Form of 11. Conver- of Deriv- vative Deri- Nature sion or ative Securi- vative of Exer- Secur- ties Secur- Indi- cise 3. ities 7. 8. Benefi- ity: rect 1. Price Trans- Acquired 6. Title and Price cially Direct Benefi- Title of of action 4. (A) or Date Exer- Amount of of Deriv- Owned at (D) or cial Deriv- Deriv- Date Trans- Disposed cisable and Underlying ative End of Indirect Owner- ative ative (Month/ action of (D) Expiration Securities Security Month (I) ship Security Secur- Day/ Code (Instr. 3, Date(Month/ (Instr. 3 (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity Year) (Instr. 8) 4 and 5) Day/Year) and 4) 5) 4) 4) 4) ---------- ------- ------- ---------- ---------- --------------- ---------------- -------- -------- -------- ------- Code V (A) (D) Date ---- - --- --- Exer- Expir- Amount or cis- ation Number of able Date Title Shares ----- ------ ----- --------- Warrant $1.925 12/29/00 P 142,857 12/29/00 12/29/05 Common 142,857 (1) 142,857 D Stock $.01 par value
Explanation of Responses: (1) Each Warrant was sold as part of a Unit that consisted of one share of Common Stock of the Company and one five-year Common Stock purchase Warrant. The purchase price of each Unit was $1.75, and the Warrant exercise price is $1.925, subject to adjustment. SIGNATURE OF REPORTING PERSON: /s/ John A. Dore ------------------------------ John A. Dore Dated: January 10, 2001 -----END PRIVACY-ENHANCED MESSAGE-----