-----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, ARV258adNcm1YU6F1nnb9+M0972w5ZwY3ZzOTNdE0tqkiLIOKxRBIJYs0mjBs6ba SFJWnxBHtx5BqIlRudDFYQ== 0000008177-03-000036.txt : 20030214 0000008177-03-000036.hdr.sgml : 20030214 20030214111550 ACCESSION NUMBER: 0000008177-03-000036 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20030201 FILED AS OF DATE: 20030214 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: ROBINSON HARRIETT J CENTRAL INDEX KEY: 0001196567 RELATIONSHIP: OWNER FILING VALUES: FORM TYPE: 5 BUSINESS ADDRESS: STREET 1: 3500 TUXEDO ROAD NW CITY: ATLANTA STATE: GA ZIP: 30305 BUSINESS PHONE: 4042665532 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: 1934 Act SEC FILE NUMBER: 000-03722 FILM NUMBER: 03563800 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 form5_0203.txt ANNUAL STMT OF 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 [x] Form 4 Transactions Reported ________________________________________________________________________________ 1. Name and Address of Reporting Person* Robinson Harriett J. - -------------------------------------------------------------------------------- (Last) (First) (Middle) 3500 Tuxedo Road, N.W. - -------------------------------------------------------------------------------- (Street) Atlanta Georgia 30305-1068 - -------------------------------------------------------------------------------- (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 February, 2003 ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Year) ________________________________________________________________________________ 6. Relationship of Reporting Person to Issuer (Check all applicable) [X] Director [X] 10% Owner [ ] Officer (give title below) [X] Other (specify below) Trustee under Rule 16a-8 ________________________________________________________________________________ 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 10,717 I 1*** - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock N/A 6,720 I 2 - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock N/A 1,971,623 I 3*** - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock N/A 3,411,102 I 4*** - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock N/A 3,953,256 I 5*** - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock N/A 4,026,992 I 6*** - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock N/A 434,812 D ====================================================================================================================================
* 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 (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 N/A Cmn. Stk. 100,000 I 7*** - ------------------------------------------------------------------------------------------------------------------------------------ Option to Buy N/A Cmn. Stk. 5,000 D 8 - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: ***Reporting person expressly disclaims beneficial ownership of such securities. 1 401(k)Plan by Spouse. Information herein is based on a plan statement as of December 31, 2002. 2 Joint with grandson. 3 Includes 740,921 shares held directly by spouse; 936,702 shares held by Delta Life Ins. Co.; and 294,000 shares held by Delta Fire & Casualty Ins. Co. 4 By Gulf Capital Services. Spouse individually holds a 24% interest in the Partnership. The remaining partnerships are held in equal shares by Trust for the benefit of the reporting person's daughters, with the reporting person as Trustee. 5 By self as Trustee for Robin Robinson, securities directly held by Trust. 6 By self as Trustee for Jill Robinson, securities directly held by Trust. 7 By spouse, option to buy Common Stock, granted at an option price of $3.374 per share under the Atlantic American Corporation 1992 Incentive Plan. 7 Granted pursuant to the Company's 1996 Director Stock Option Plan at option prices ranging from $1.90 to $4.4375. 02/14/03 - --------------------------------------------- ----------------------- Harriett J. Robinson 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-----