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: Edwin W. Elder 2509 Stowebridge Lane Northbrook, Illinois 60062 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): July 1997 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 12/30/00 A 958 A $1.88 1,321(1) D Stock, $0.01 par value (1) Includes 958 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 ----- ----- ----- ---------
Explanation of Responses: SIGNATURE OF REPORTING PERSON: /s/ Edwin W. Elder ------------------------------ Edwin W. Elder Dated: January 10, 2001