5/A 1 simses.txt | OMB APPROVAL | | | | OMB Number: 3235-0362 | | Expires: January 31, 2005 | | Estimated average burden | FORM 5 | hours per response......1.0 | 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(h) of the Investment Company Act of 1940 [_] Check this 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* Simses Robert G. ------------------------------------------------------------------------------- (Last) (First) (Middle) c/o NYMAGIC, INC. 330 Madison Avenue ------------------------------------------------------------------------------- (Street) New York NY 10017 ------------------------------------------------------------------------------- (City) (State) (Zip) ------------------------------------------------------------------------------- 2. Issuer Name and Ticker or Trading Symbol NYMAGIC, INC. ("NYM") ------------------------------------------------------------------------------- 3. I.R.S. Identification Number of Reporting Person, if an Entity (voluntary) ------------------------------------------------------------------------------- 4. Statement for Month/Year 12/2001 ------------------------------------------------------------------------------- 5. If Amendment, Date of Original (Month/Year) 2/8/2002 ------------------------------------------------------------------------------- 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 Reporting (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 =================================================================================================================================== 2A. 5. Deemed 4. Amount of 6. 7. 2. Exe- Securities Acquired (A) Securities Ownership Nature of Trans- cution or Disposed of (D) Beneficially Form: Indirect action Date, 3. (Instr. 3, 4 and 5) Owned at End Direct Bene- Date if any Trans- ----------------------- of Issuer's (D) or ficial 1. (Month/ (Month/ action (A) Fiscal Year Indirect Owner- Title of Security Day/ Day/ Code or (Instr. 3 (I) ship (Instr.3) Year) Year) (Instr.8) Amount (D) Price and 4) (Instr.4) (Instr. 4) ----------------------------------------------------------------------------------------------------------------------------------- (1) 12/20/2000 ----------------------------------------------------------------------------------------------------------------------------------- Common stock 6/6/2001 A(2) 454 A (2) 454 D ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- =================================================================================================================================== * If the form is filed by more than one reporting person, see instruction 4(b)(v). Persons who responds to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number (Over) SEC 2270 (3-99)
FORM 5 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ==================================================================================================================================== 10. 9. Owner- Number ship of Form 2. Deriv- of Conver- 5. 7. ative Deriv- 11. sion Number of Title and Amount Secur- ative Nature or 3A. Derivative 6. of Underlying 8. ities Secur- of Exer- Deemed Securities Date Securities Price Bene- ity In- cise 3. Exe- Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct Price Trans- cution 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene- 1. of action Date, Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial Title of Deriv- Date if any action (Instr. 3, ---------------- or Secur- of direct Owner- Derivative ative (Month/ (Month/ Code 4 and 5) Date Expira- Number ity Year (I) ship Security Secur- Day/ Day/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity Year) Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4) ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ==================================================================================================================================== Explanation of Responses: (1) On 12/20/2000, Mr. Simses becme a 10% beneficial owner for reporting purposes by reason of being trustee of a trust that is a 10% beneficial owner, but he did not as of that date have a direct or indirect pecuniary interest in any securities of the issuer. (2) On 5/16/2001, Mr. Simses was elected a director of the issuer. Shares were awarded to Mr. Simses by the issuer on 6/6/2001 as part of his director compensation.
/s/ Robert G. Simses 10/12/02 -------------------------------------------- ----------------------- **Signature of Reporting Person Date ** 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. Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB number. Page 2