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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, DC 20549
FORM 4
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).
(Print of Type Responses)
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1. Name and Address of Reporting Person*
Wirch John R
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(Last) (First) (Middle)
3100 AMS Boulevard
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(Street)
Green Bay WI 54313
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(City) (State) (Zip)
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2. Issuer Name and Ticker or Trading Symbol
American Medical Security Group, Inc. (AMZ)
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3. I.R.S. Identification Number of Reporting Person, if an entity (voluntary)
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4. Statement for Month/Day/Year
02/26/03
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5. If Amendment, Date of Original (Month/Day/Year)
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6. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
|_| Director |_| 10% Owner
|x| Officer (give title below) |_| Other (specify below)
Vice President, Human Resources
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7. Individual or Joint/Group Filing (Check Applicable line)
|x| Form Filed by One Reporting Person
|_| Form Filed by More than One Reporting Person
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Table I -- Non-Derivative Securities Acquired, Disposed of,
or Beneficially Owned
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6.
4. 5. Owner-
Securities Acquired (A) or Amount of ship
3. Disposed of (D) Securities Form: 7.
2A. Transaction (Instr. 3, 4 and 5) Beneficially Direct Nature of
2. Deemed Exec- Code ------------------------------- Owned Follow- (D) or Indirect
1. Transaction ution Date, (Instr. 8) (A) ing Reported Indirect Beneficial
Title of Security Date if any ------------ Amount or Price Transactions (I) Ownership
(Instr. 3) (mm/dd/yy) (mm/dd/yy) Code V (D) (Instr.3 & 4) (Instr.4) (Instr. 4)
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Common Stock 02/26/03 P 500 A $13.05 1,000 D
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FORM 4 (continued)
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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9.
Number
10.
of
Owner-
deriv-
ship
ative
Form
2. Secur- of
Conver- 5. 7. ities Deriv- 11.
sion Number of Title and Amount Bene- ative Nature
or Derivative 6. of Underlying 8. ficially Secur- of
Exer- 3A. 4. Securities Date Securities Price Owned ity: In-
cise Deemed Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of Follow- Direct direct
Price 3. Execut- action or Disposed Expiration Date ---------------- Deriv- ing (D) or Bene-
1. of Trans- ion Code of(D) (Month/Day/Year) Amount ative Reported In- ficial
Title of Deriv- action Date if (Instr. (Instr. 3, ---------------- or Secur- Trans- direct Owner-
Derivative ative Date any 8) 4 and 5) Date Expira- Number ity action(s) (I) ship
Security Secur- (mm/dd/ (mm/dd/ ------ ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity yy) yy) Code V (A) (D) cisable Date Title Shares 5) 4) 4) 4)
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Explanation of Responses:
/s/ John R. Wirch 02/27/03
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**Signature of Reporting Person Date
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction
4(b)(v).
** 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 is insufficient, see Instruction 6 for procedure.
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