-----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, NF9C/6omLjDSFSJVVNPFP+KPaz+pHFycVldZchShoKZPOisTMhqR79ctGfHAtyXv q4xu6dMkw9Jx8+14p7ejqw== 0000908662-02-000060.txt : 20020414 0000908662-02-000060.hdr.sgml : 20020414 ACCESSION NUMBER: 0000908662-02-000060 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20011231 FILED AS OF DATE: 20020220 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: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 000-22922 FILM NUMBER: 02554597 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: VIGILANCE SYSTEMS CORP DATE OF NAME CHANGE: 19920202 FORMER COMPANY: FORMER CONFORMED NAME: WESTERN TRANSMEDIA CO INC DATE OF NAME CHANGE: 19920703 COMPANY DATA: COMPANY CONFORMED NAME: KINGSWAY FINANCIAL SERVICES INC CENTRAL INDEX KEY: 0001072627 STANDARD INDUSTRIAL CLASSIFICATION: FIRE, MARINE & CASUALTY INSURANCE [6331] OWNER STATE OF INCORPORATION: A6 FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: 5310 EXPLORER DRIVE STREET 2: MISSISSAUGA ONTARIO CANADA L4W 5H8 CITY: MISSISSAUGA BUSINESS PHONE: 8476197610 MAIL ADDRESS: STREET 1: 5310 EXPLORER DRIVE STREET 2: MISSISSAUGA ONTARIO CANADA L4W 5H8 CITY: MISSISSAUGA STATE: A6 5 1 kingsway_form5.txt FORM 5 U.S. SECURITIES AND EXCHANGE COMMISSION Washington, DC 20549 FORM 5 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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 [_] Check box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). [x] Form 3 Holdings Reported [_] Form 4 Transactions Reported ________________________________________________________________________________ 1. Name and Address of Reporting Person* Kingsway Financial Services Inc. - -------------------------------------------------------------------------------- (Last) (First) (Middle) 5310 Explorer Drive - -------------------------------------------------------------------------------- (Street) Mississauga, Ontario L4W 5H8 Canada - -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Issuer Name and Ticker or Trading Symbol American Country Holdings, Inc. (ACHI) ________________________________________________________________________________ 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) ________________________________________________________________________________ 4. Statement for Month/Year December 31, 2001 ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Year) ________________________________________________________________________________ 6. Relationship of Reporting Person to Issuer (Check all applicable) [_] Director [x] 10% Owner [_] Officer (give title below) [_] Other (specify below) ________________________________________________________________________________ 7. Individual or Joint/Group Filing (Check applicable line) [_] Form filed by one Reporting Person [x] Form filed by more than one Reporting Person ________________________________________________________________________________ ================================================================================ Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned ================================================================================
5. 6. 4. Amount of Owner- Securities Acquired (A) or Securities ship Disposed of (D) Beneficially Form: 7. (Instr. 3, 4 and 5) Owned at End Direct Nature of 2. 3. ----------------------------- of Issuer's (D) or Indirect 1. Transaction Transaction (A) Fiscal Year Indirect Beneficial Title of Security Date Code Amount or Price (Instr. 3 (I) Ownership (Instr. 3) (mm/dd/yy) (Instr. 8) (D) and 4) (Instr.4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 7/2/01 P3(1) 555,471 A $1.9035 1,126,900 D per share - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
* If the form is filed by more than one Reporting Person, see Instruction 4(b)(v). Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Print or Type Responses) (Over) FORM 5 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================
9. 10. Number Owner- of ship 2. Deriv- of Conver- 5. 7. ative Deriv- 11. sion Number of Title and Amount Secur- ative Nature or Derivative 6. of Underlying 8. ities Secur- of Exer- Securities Date Securities Price Bene- ity: In- cise 3. Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct Price Trans- 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene- 1. of action Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial Title of Deriv- Date action (Instr. 3, ---------------- or Secur- of direct Owner- Derivative ative (Month/ Code 4 and 5) Date Expira- Number ity Year (I) ship Security Secur- Day/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4) - ------------------------------------------------------------------------------------------------------------------------------------ Series A $1.75 12/27/00 P3(1) 100,000 Immed- N/A Common 571,429 $10 per 1,126,900 D Convertible iately Stock share Preferred Stock - ------------------------------------------------------------------------------------------------------------------------------------ Explanation of Responses: (1) The reporting person acquired 555,471 shares of Common Stock on July 2, 2001. When added to the number of shares of the report- ing person's prior holdings of Series A Convertible Preferred Stock which are convertible into Common Stock, this purchase on July 2, 2001 caused the reporting person to become a 10% owner of American Country Holdings, Inc. ====================================================================================================================================
/s/ William G. Star February 20, 2002 - --------------------------------------------- ----------------------- **Signature of Reporting Person Date WILLIAM STAR PRESIDENT ** 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. JOINT FILER INFORMATION Name: American Service Insurance Company, Inc. Address: c/o Kingsway Financial Services, Inc. 5310 Explorer Drive Mississauga, Ontario L4W5H8 Canada Designated Filer: Kingsway Financial Services Inc. Date of Event Requiring Statement: July 2, 2001 Signature: /s/ James R. Zuhlke ----------------------------- Name: James R. Zuhlke Title: Chairman JOINT FILER INFORMATION Name: Lincoln General Insurance Company Address: c/o Kingsway Financial Services, Inc. 5310 Explorer Drive Mississauga, Ontario L4W5H8 Canada Designated Filer: Kingsway Financial Services Inc. Date of Event Requiring Statement: July 2, 2001 Signature: /s/ William G. Star ----------------------------- Name: William G. Star Title: President and Chief Executive Officer JOINT FILER INFORMATION Name: Universal Casualty Company Address: c/o Kinsway Financial Services, Inc. 5310 Explorer Drive Mississauga, Ontario L4W5H8 Canada Designated Filer: Kingsway Financial Services Inc. Date of Event Requiring Statement: July 2, 2001 Signature: /s/ Marc Romanz ----------------------------- Name: Marc Romanz Title: Chief Operating Officer -----END PRIVACY-ENHANCED MESSAGE-----