3 1 e-6836.txt FORM 3 OF MERRYMEETING, INC. ------------------------------ OMB APPROVAL ------------------------------ ------ OMB Number 3235-0104 FORM 3 Expires: December 31, 2001 ------ Estimated average burden hours per response ....... 0.5 ------------------------------ U.S. SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES 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 ================================================================================ 1. Name and Address of Reporting Person Merrymeeting, Inc. -------------------------------------------------------------------------------- (Last) (First) (Middle) c/o Ulmer & Berne LLP 1300 East 9th Street, Suite 900 -------------------------------------------------------------------------------- (Street) Cleveland Ohio 44114-1583 -------------------------------------------------------------------------------- (City) (State) (Zip) ================================================================================ 2. Date of Event Requiring Statement (Month/Day/Year) May 2, 2001 ================================================================================ 3. IRS or Social Security Number of Reporting Person (Voluntary) ================================================================================ 4. Issuer Name and Ticker or Trading Symbol Frontier Adjusters of America, Inc. (FAJ) ================================================================================ 5. Relationship of Reporting Person to Issuer (Check all applicable) [ ] Director [X] 10% Owner [ ] Officer (give title below) [ ] Other (specify below) -------------------------------------------------------------------- ================================================================================ 6. If Amendment, Date of Original (Month/Year) ================================================================================ 7. Individual or Joint/Group Filing (Check Applicable Line) [ ] Form filed by One Reporting Person [X] Form filed by More than One Reporting Person ================================================================================ FORM 3 (continued) Table I -- Non-Derivative Securities Beneficially Owned ================================================================================ 3. Ownership Form: 1. Title of 2. Amount of Securities Direct (D) or 4. Nature of Indirect Security Beneficially Owned Indirect (I) Beneficial Ownership (Instr. 4) (Instr. 4) (Instr. 5) (Instr.5) -------------------------------------------------------------------------------- Common Stock 5,258,513(1)(2)(3) D -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- ================================================================================ ---------- (1) These securities are owned solely by Merrymeeting, Inc. (2) IVM Intersurer BV is a 50% shareholder of Merrymeeting, Inc., which owns 5,258,513 shares of Frontier common stock. This amount includes 2,629,257 shares, or 50% of the Frontier shares held by Merrymeeting, Inc., with regard to which IVM Intersurer BV disclaims any beneficial interest. This report shall not be deemed an admission that IVM Intersurer BV is the beneficial owner of such securities for purposes of Section 16 or for any other purpose. (3) Patrick Enthoven is the Chief Advisor of Insurance Operations of IVM Intersurer BV, which is a 50% shareholder of Merrymeeting, Inc., which owns 5,258,513 shares of Frontier common stock with regard to which Patrick Enthoven disclaims any beneficial interest. This report shall not be deemed an admission that Patrick Enthoven is the beneficial owner of such securities for purposes of Section 16 or for any other purpose.
Table II -- Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ===================================================================================================== 3. Title and Amount of Securities Underlying 5. Owner- Derivative Security ship 2. Date Exercisable (Instr. 4) Form of and Expiration Date ------------------------ 4. Conver- Derivative (Month/Day/Year) Amount sion or Security: 6. Nature of 1. Title of --------------------- or Exercise Direct Indirect Derivative Date Expira- Number Price of (D) or Beneficial Security Exer- tion of Derivative Indirect(I) Ownership (Instr. 4) cisable Date Title Shares Security (Instr.5) (Instr. 5) ----------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------- =====================================================================================================
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. Explanation of Responses: By: /s/ John M. Davies May 15, 2001 --------------------------- ------------ Its: President Date -------------------------- **Signature of Reporting Person * If the form is filed by more than one reporting person, see Instruction 5(b)(v). ** Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). JOINT FILER INFORMATION Name: IVM Intersurer BV Address: Strawinskylaan 1725 1007 XX Amsterdam The Netherlands Designated Filer: Merrymeeting, Inc. Issuer & Ticker Symbol: Frontier Adjusters of America, Inc. (FAJ) Date of Event Requiring Statement: May 2, 2001 Signature: /s/ John M. Davies -------------------------------------- as President of Merrymeeting, Inc. Name: Patrick Enthoven Address: c/o Ulmer & Berne LLP 1300 East 9th Street, Suite 900 Cleveland, Ohio 44114-1583 Designated Filer: Merrymeeting, Inc. Issuer & Ticker Symbol: Frontier Adjusters of America, Inc. (FAJ) Date of Event Requiring Statement: May 2, 2001 Signature: /s/ John M. Davies -------------------------------------- as President of Merrymeeting, Inc. CONFIRMING STATEMENT This Statement confirms that the undersigned, IVM Intersurer BV, has authorized and designated John M. Davies, as President of Merrymeeting, Inc., a Delaware corporation, to execute and file on the undersigned's behalf all Forms 3, 4, and 5 (including any amendments thereto) that the undersigned may be required to file with the U.S. Securities and Exchange Commission as a result of the undersigned's ownership of or transactions in securities of Frontier Adjusters of America, Inc. The authority of John M. Davies, as President of Merrymeeting, Inc., a Delaware corporation, under this Statement shall continue until the undersigned is no longer required to file Forms 3, 4, and 5 with regard to its ownership of or transactions in securities of Frontier Adjusters of America, Inc., unless earlier revoked in writing. The undersigned acknowledges that John M. Davies, as President of Merrymeeting, Inc., a Delaware corporation, is not assuming any of the undersigned's responsibilities to comply with Section 16 of the Securities Exchange Act of 1934. Dated: May 15, 2001 IVM Intersurer BV, a Netherlands holding company By: /s/ Patrick Enthoven -------------------------------------- Name: Patrick Enthoven Title: Chief Advisor of Insurance Operations CONFIRMING STATEMENT This Statement confirms that the undersigned, Patrick Enthoven, has authorized and designated John M. Davies, as President of Merrymeeting, Inc., a Delaware corporation, to execute and file on the undersigned's behalf all Forms 3, 4, and 5 (including any amendments thereto) that the undersigned may be required to file with the U.S. Securities and Exchange Commission as a result of the undersigned's ownership of or transactions in securities of Frontier Adjusters of America, Inc. The authority of John M. Davies, as President of Merrymeeting, Inc., a Delaware corporation, under this Statement shall continue until the undersigned is no longer required to file Forms 3, 4, and 5 with regard to its ownership of or transactions in securities of Frontier Adjusters of America, Inc., unless earlier revoked in writing. The undersigned acknowledges that John M. Davies, as President of Merrymeeting, Inc., a Delaware corporation, is not assuming any of the undersigned's responsibilities to comply with Section 16 of the Securities Exchange Act of 1934. Dated: May 15, 2001 /s/ Patrick Enthoven ---------------------------------------- Patrick Enthoven