-----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, I5qRwWP8VXt4S+EQymYNnb04SS2P7c/KNrjGm5ECtwOHc34vw5/MmtMWv7AWuHXI qTk5f0C6K284w8h7PaZdOQ== 0000008177-99-000004.txt : 19990205 0000008177-99-000004.hdr.sgml : 19990205 ACCESSION NUMBER: 0000008177-99-000004 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 19981231 FILED AS OF DATE: 19990204 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: ATLANTIC AMERICAN CORP CENTRAL INDEX KEY: 0000008177 STANDARD INDUSTRIAL CLASSIFICATION: LIFE INSURANCE [6311] IRS NUMBER: 581027114 STATE OF INCORPORATION: GA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 SEC ACT: SEC FILE NUMBER: 000-03722 FILM NUMBER: 99520778 BUSINESS ADDRESS: STREET 1: 4370 PEACHTREE RD NE CITY: ATLANTA STATE: GA ZIP: 30319 BUSINESS PHONE: 4042665500 MAIL ADDRESS: STREET 1: 4370 PEACHTREE ROAD CITY: ATLANTA STATE: GA ZIP: 30319 COMPANY DATA: COMPANY CONFORMED NAME: ATLANTIC AMERICAN CORP CENTRAL INDEX KEY: 0000008177 STANDARD INDUSTRIAL CLASSIFICATION: LIFE INSURANCE [6311] DIRECTOR IRS NUMBER: 581027114 STATE OF INCORPORATION: GA FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: 4370 PEACHTREE RD NE CITY: ATLANTA STATE: GA ZIP: 30319 BUSINESS PHONE: 4042665500 MAIL ADDRESS: STREET 1: 4370 PEACHTREE ROAD CITY: ATLANTA STATE: GA ZIP: 30319 5 1 ANNUAL STATEMENT/CHANGES IN BENEFICIAL OWNERSHIP ------------------------------ OMB APPROVAL ------------------------------ OMB Number Expires: Estimated average burden hours per response ....... 1.0 ------------------------------ U.S. SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 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). [_] Form 3 Holdings Reported [_] Form 4 Transactions Reported ________________________________________________________________________________ 1. Name and Address of Reporting Person* Howell, Jr. Hilton H. - -------------------------------------------------------------------------------- (Last) (First) (Middle) 4370 Peachtree Road, NE - -------------------------------------------------------------------------------- (Street) Atlanta Georgia 30319-3000 - -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Issuer Name and Ticker or Trading Symbol Atlantic American Corporation - AAME ________________________________________________________________________________ 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) ###-##-#### ________________________________________________________________________________ 4. Statement for Month/Year December, 1998 ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Year) ________________________________________________________________________________ 6. Relationship of Reporting Person to Issuer (Check all applicable) [X] Director [X] 10% Owner [X] Officer (give title below) [ ] Other (specify below) President & CEO ________________________________________________________________________________ 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. 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 10,766(1) I 401(k) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock N/A 27,900 D - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock N/A 1,025 I By Spouse(2) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock N/A 6,720 I Joint by Son with Harriett J. Robinson(2) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
* 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. (Over) (Form 5-07/98) 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) - ------------------------------------------------------------------------------------------------------------------------------------ Employee Stock Option $3.734 10/27/98 A(3) 50,000 10/27/98 10/27/03 Cmn. Stk. 50,000 D - ------------------------------------------------------------------------------------------------------------------------------------ Employee Stock Option $3.734 10/27/98 A(3) 25,000 10/27/99 10/27/03 Cmn. Stk. 25,000 D - ------------------------------------------------------------------------------------------------------------------------------------ Employee Stock Option $3.734 10/27/98 A(3) 25,000 10/27/00 10/27/03 Cmn. Stk. 25,000 D - ------------------------------------------------------------------------------------------------------------------------------------ Employee Stock Option $4.25 10/31/97 D(4) 100,000 10/31/97 10/31/02 Cmn. Stk. 100,000 D - ------------------------------------------------------------------------------------------------------------------------------------ Employee Stock Option $3.75 12/14/98 A(5) 100,000 10/31/97 10/31/02 Cmn. Stk. 100,000 320,000 D - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: 1 The information herein is based on a plan statement as of January 5, 1999. 2 Reporting Person expressly disclaims beneficial ownership of such securities. 3 Option to buy 100,000 shares Common Stock, exempt under Rule 16b-3, of which 50% were exercisable on 10/27/98; an additional 25% are excercisable 10/27/99; and the remaining 25% are exercisable on 10/27/00. These options are granted under the Atlantic American Corporation 1992 Incentive Plan. 4 Cancellation of option in connection with grant of replacement option. 5 The reported transaction involved the repricing of existing options that were originally granted on October 31, 1997 for 100,000 shares, of which 50% were exercisable on October 31, 1997, an additional 25% were exercisable on October 31, 1998 and the remaining 25% are exercisable on October 31, 1999. The vesting terms were not amended at the time of repricing. 1/29/99 - --------------------------------------------- ----------------------- Hilton H. Howell, Jr. Date **Signature of Reporting Person ** 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. Page 2 -----END PRIVACY-ENHANCED MESSAGE-----