------------------------------
OMB APPROVAL
------------------------------
OMB Number: 3235-0362
Expires: January 31, 2005
Estimated average burden
hours per response.........1.0
------------------------------
UNITED STATES 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 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*
Miller Samuel V.
--------------------------------------------------------------------------------
(Last) (First) (Middle)
3100 AMS Boulevard
--------------------------------------------------------------------------------
(Street)
Green Bay WI 54313
--------------------------------------------------------------------------------
(City) (State) (Zip)
--------------------------------------------------------------------------------
2. Issuer Name and Ticker or Trading Symbol
American Medical Security Group, Inc. (AMZ)
--------------------------------------------------------------------------------
3. I.R.S. Identification Number of Reporting Person, if an entity (Voluntary)
--------------------------------------------------------------------------------
4. Statement for Month/Year
December, 2002
--------------------------------------------------------------------------------
5. If Amendment, Date of Original (Month/Year)
--------------------------------------------------------------------------------
6. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|x| Director |_| 10% Owner
|x| Officer (give title below) |_| Other (specify below)
Chairman, President and Chief Executive Officer
--------------------------------------------------------------------------------
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
================================================================================
6.
4. 5. Owner- 7.
Securities Acquired (A) Amount of ship Nature of
2. 2A. or Disposed of (D) Securities Form: Indirect
Trans- Deemed (Instr. 3, 4 and 5) Beneficially Direct Bene-
action Execution 3. Owned at end (D) or ficial
1. Date Date, If Transaction (A) of Issuer's Indirect Owner-
Title of Security (month/ any (month/ Code or Fiscal Year (I) ship
(Instr. 3) day/year) day/year) (Instr.8) Amount (D) Price (Instr. 3 & 4) (Instr.4) (Instr.4)
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
====================================================================================================================================
* If the form is filed by more than one reporting person, see instruction
4(b)(v).
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
2. of of
Conver- 5. 7. Deriv- Deriv- 11.
sion Number of Title and Amount ative ative Nature
or Derivative 6. of Underlying 8. Secur- Secur- of
Exer- 3A. Securities Date Securities Price ities ity: In-
cise Deemed Acquired (A) Exercisable and (Instr. 3 and 4) of Bene- Direct direct
Price 3. Execut- 4. or Disposed Expiration Date ---------------- Deriv- ficially (D) or Bene-
1. of Trans- ion Trans- of(D) (Month/Day/Year) Amount ative Owned In- ficial
Title of Deriv- action Date if action (Instr. 3, ---------------- or Secur- at End direct Owner-
Derivative ative Date any Code 4 and 5) Date Expira- Number ity of Year (I) ship
Security Secur- (mm/dd/ (mm/dd/ (Instr. Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity yy) yy) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4)
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
Employee $12.25 1/10/02 A 160,000 (1) 1/9/14 Common 160,000 160,000 D
Stock Option Stock
(Right to
Buy)
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
====================================================================================================================================
Explanation of Responses:
(1) Option vests in four (4) equal annual installments beginning 1/10/03.
/s/ Samuel V. Miller 2/12/03
--------------------------------------------- -----------------------
**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.