SECURITIES AND EXCHANGE COMMISSION WASHINGTON, D.C. 20549 SCHEDULE 13G (Rule 13d-102) INFORMATION TO BE INCLUDED IN STATEMENTS FILED PURSUANT TO RULES 13d-1(b)(c) AND (d) AND AMENDMENTS THERETO FILED PURSUANT TO RULE 13d-2(b) (AMENDMENT NO. 5) (1) AMERICAN MEDICAL SECURITY GROUP, INC. ------------------------------------------------------------------------------- (Name of Issuer) COMMON STOCK ------------------------------------------------------------------------------- (Title of Class of Securities) 02744P101 ------------------------------------------------------------------------------- (CUSIP Number) December 31, 2003 ------------------------------------------------------------------------------- (Date of Event Which Requires Filing of This Statement) Check the appropriate box to designate the rule pursuant to which this Schedule is filed: [ ] Rule 13d-1(b) [ ] Rule 13d-1(c) [X] Rule 13d-1(d) ------------ (1) The remainder of this cover page shall be filled out for a reporting person's initial filing on this form with respect to the subject class of securities, and for any subsequent amendment containing information which would alter the disclosures provided in a prior cover page. The information required in the remainder of this cover page shall not be deemed to be "filed" for the purpose of Section 18 of the Securities Exchange Act of 1934 ("Act") or otherwise subject to the liabilities of that section of the Act but shall be subject to all other provisions of the Act (however, see the Notes). -------------------- CUSIP NO. 02744P101 13G -------------------- -------------------------------------------------------------------------------- 1 NAME OF REPORTING PERSON I.R.S. IDENTIFICATION OF ABOVE PERSON Samuel V. Miller -------------------------------------------------------------------------------- 2 CHECK THE APPROPRIATE BOX IF A MEMBER OF A GROUP (a) [ ] (b) [ ] -------------------------------------------------------------------------------- 3 SEC USE ONLY -------------------------------------------------------------------------------- 4 CITIZENSHIP OR PLACE OF ORGANIZATION U.S.A. -------------------------------------------------------------------------------- 5 SOLE VOTING POWER 914,699 NUMBER OF ---------------------------------------------------- SHARES 6 SHARED VOTING POWER BENEFICIALLY OWNED BY 6,500 EACH ---------------------------------------------------- REPORTING 7 SOLE DISPOSITIVE POWER PERSON WITH 914,699 ---------------------------------------------------- 8 SHARED DISPOSITIVE POWER 6,500 -------------------------------------------------------------------------------- 9 AGGREGATE AMOUNT BENEFICIALLY OWNED BY EACH REPORTING PERSON 921,199 -------------------------------------------------------------------------------- 10 CHECK BOX IF THE AGGREGATE AMOUNT IN ROW (9) EXCLUDES CERTAIN SHARES [ ] -------------------------------------------------------------------------------- 11 PERCENT OF CLASS REPRESENTED BY AMOUNT IN ROW (9) 6.4% -------------------------------------------------------------------------------- 12 TYPE OF REPORTING PERSON IN -------------------------------------------------------------------------------- 2 ITEM 1 (a) NAME OF ISSUER: American Medical Security Group, Inc. (b) ADDRESS OF ISSUER'S PRINCIPAL EXECUTIVE OFFICES: 3100 AMS Boulevard Green Bay, Wisconsin 54313 ITEM 2 (a) NAME OF PERSON FILING: Samuel V. Miller (b) ADDRESS OF PRINCIPAL BUSINESS OFFICE: 3100 AMS Boulevard Green Bay, Wisconsin 54313 (c) CITIZENSHIP: U.S.A. (d) TITLE OF CLASS OF SECURITIES: Common Stock (e) CUSIP NUMBER: 02744P101 ITEM 3 IF THIS STATEMENT IS FILED PURSUANT TO RULE 13D-1(b) OR RULE 13d-2(b) OR (c) CHECK WHETHER THE PERSON FILING IS A: (a) [ ] Broker or dealer registered under Section 15 of the Exchange Act; (b) [ ] Bank as defined in Section 3(a)(6) of the Exchange Act; (c) [ ] Insurance company as defined in Section 3(a)(19) of the Exchange Act; (d) [ ] Investment company registered under Section 8 of the Investment Company Act; (e) [ ] Investment adviser in accordance with Rule 13d-1(b)(1)(ii)(E); (f) [ ] Employee benefit plan or endowment fund in accordance with Rule 13d-1(b)(1)(ii)(F); (g) [ ] Parent holding company or control person in accordance with Rule 13d-1(b)(1)(ii)(G); (h) [ ] Savings association as defined in Section 3(b) of the Federal Deposit Insurance Act; (i) [ ] Church plan that is excluded from the definition of an investment company under Section 3(c)(14) of the Investment Company Act; (j) [ ] Group, in accordance with Rule 13d-1(b)(1)(ii)(J). 3 ITEM 4 OWNERSHIP. (a) Amount beneficially owned: 921,199* *Includes 847,693 shares that may be acquired pursuant to employee stock options which were exercisable within 60 days of December 31, 2003, and 73,506 shares of deferred stock that shall be issued to Mr. Miller upon his termination of employment with American Medical Security Group, Inc. (b) Percent of Class: 6.4% (c) Number of shares as to which such person has: (i) Sole power to vote or direct the vote: 914,699 (ii) Shared power to vote or direct the vote: 6,500 (iii) Sole power to dispose or direct the disposition of: 914,699 (iv) Shared power to dispose or direct the disposition of: 6,500 ITEM 5 OWNERSHIP OF FIVE PERCENT OR LESS OF A CLASS. If this statement is being filed to report the fact that as of the date hereof the reporting person has ceased to be the beneficial owner of more than five percent of the class of securities, check the following [ ]. ITEM 6 OWNERSHIP OF MORE THAN FIVE PERCENT ON BEHALF OF ANOTHER PERSON. Not Applicable ITEM 7 IDENTIFICATION AND CLASSIFICATION OF THE SUBSIDIARY WHICH ACQUIRED THE SECURITY BEING REPORTED ON BY THE PARENT HOLDING COMPANY OR CONTROL PERSON. Not Applicable. ITEM 8 IDENTIFICATION AND CLASSIFICATION OF MEMBERS OF THE GROUP. Not Applicable. ITEM 9 NOTICE OF DISSOLUTION OF GROUP. Not Applicable. ITEM 10 CERTIFICATIONS. Not Applicable 4 SIGNATURE After reasonable inquiry and to the best of my knowledge and belief, I certify that the information set forth in this statement is true, complete and correct. February 11, 2004 ----------------------------- (Date) /s/ Samuel V. Miller ----------------------------- Samuel V. Miller 5