0001209191-15-012743.txt : 20150212 0001209191-15-012743.hdr.sgml : 20150212 20150212162704 ACCESSION NUMBER: 0001209191-15-012743 CONFORMED SUBMISSION TYPE: 5 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20141231 FILED AS OF DATE: 20150212 DATE AS OF CHANGE: 20150212 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: AMSURG CORP CENTRAL INDEX KEY: 0000895930 STANDARD INDUSTRIAL CLASSIFICATION: SERVICES-OFFICES & CLINICS OF DOCTORS OF MEDICINE [8011] IRS NUMBER: 621493316 STATE OF INCORPORATION: TN FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 20 BURTON HILLS BLVD. STREET 2: SUITE 500 CITY: NASHVILLE STATE: TN ZIP: 37215 BUSINESS PHONE: 615-665-1283 MAIL ADDRESS: STREET 1: 20 BURTON HILLS BLVD. STREET 2: SUITE 500 CITY: NASHVILLE STATE: TN ZIP: 37215 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: HERR HENRY D CENTRAL INDEX KEY: 0000903096 FILING VALUES: FORM TYPE: 5 SEC ACT: 1934 Act SEC FILE NUMBER: 001-36531 FILM NUMBER: 15606621 MAIL ADDRESS: STREET 1: ONE BURTON HILLS BLVD CITY: NASHVILLE STATE: TN ZIP: 37215 5 1 doc5.xml FORM 5 SUBMISSION X0306 5 2014-12-31 0 0 0 0000895930 AMSURG CORP AMSG 0000903096 HERR HENRY D 110 31ST AVE NORTH, UNIT 1003 NASHVILLE TN 37203 1 0 0 0 Common stock 108839 D 5.250% Mandatory Convertible Preferred Stock, Series A-1 2014-12-01 5 P 0 400 107.6875 A 2017-07-01 Common stock 400 D The Company's 5.250% mandatory convertible preferred stock, Series A-1 (the "Preferred Stock") will automatically convert on July 1, 2017. Holders of the Preferred Stock have the right to convert the Preferred Stock at any time prior to July 1, 2017 into shares of the Company's common stock. If the applicable market value of the Company's common stock is equal to or greater than $55.13, the fixed conversion rate will be 1.8141 shares of the Company's common stock per share of Preferred Stock, or a total of 725.64 shares of common stock. If the applicable market value of the Company's common stock is less than or equal to $45, the fixed conversion rate will be 2.2222 shares of the Company's common stock per share of Preferred Stock, or a total of 888.88 shares of common stock. If the applicable market value of the Company's common stock is more than $45.00 and less than $55.13, then the conversion rate will be equal to $100 divided by the applicable market value of the Company's stock. /s/ Henry D. Herr 2015-02-12