-----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, HsYqg0FGE6U3oD8qvX1Vn+n/5DDGqfsBQVp1xCXZjoj0Mzbti/DC+HMEkHgdeOPa AYo+FwcO1/RtbmamVEAxbw== 0000895813-01-000017.txt : 20010123 0000895813-01-000017.hdr.sgml : 20010123 ACCESSION NUMBER: 0000895813-01-000017 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: 1506596 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: SOLOMON MARTIN L CENTRAL INDEX KEY: 0001012912 STANDARD INDUSTRIAL CLASSIFICATION: UNKNOWN SIC - 0000 [0000] DIRECTOR FILING VALUES: FORM TYPE: 4 BUSINESS ADDRESS: STREET 1: P O BOX 70 CITY: COCONUT GROVE STATE: FL ZIP: 33133 BUSINESS PHONE: 3058563103 MAIL ADDRESS: STREET 1: P O BOC 70 CITY: COCONUT GROVE STATE: FL ZIP: 33133 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: Martin L. Solomon P.O. Box 70 Coconut Grove, Florida 33233 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): August 1997 6. Relationship of Reporting Person(s) to Issuer (Check all applicable): (x) Director (x) 10% Owner ( ) 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 ---- - ------ -------- -----
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 ----- ------ ----- --------- Series A (1) 12/29/00 P 100,000 12/29/00 Common 571,428(2) $ 10 100,000 D 6% Con- Stock vertible $.01 Preferred par Stock value
Explanation of Responses: (1) The Series A 6% Convertible Preferred Stock has a stated value of $10 per share. The conversion price of the Preferred Stock is $1.75, subject to adjustment. Each share of Preferred Stock is convertible into such number of shares of Common Stock by dividing the stated value, plus accrued but unpaid dividends by the then effective conversion price. The terms of the Preferred Stock are set forth in the Certificate of Designations, Preferences, and Rights of Series A Convertible Preferred Stock. (2) Subject to antidilution adjustment. SIGNATURE OF REPORTING PERSON: /s/ Martin L. Solomon ------------------------------ Martin L. Solomon Dated: January 10, 2001 -----END PRIVACY-ENHANCED MESSAGE-----