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OMB APPROVAL
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OMB Number 3235-0287
Expires: January 31, 2005
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 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).
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1. Name and Address of Reporting Person*
BLUE CROSS & BLUE SHIELD UNITED OF WISCONSIN (1)
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(Last) (First) (Middle)
401 WEST MICHIGAN STREET
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(Street)
MILWAUKEE, WI 53203
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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. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
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4. Statement for Month/Day/Year
January 3, 2003
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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 [X] 10% Owner
[_] Officer (give title below) [_] Other (specify below)
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7. Individual or Joint/Group Filing (Check applicable line)
[_] Form filed by one Reporting Person
[X] 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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5. 6.
2A. 4. Amount of Owner-
Deemed Securities Acquired (A) or Securities ship
2. Execution 3. Disposed of (D) Beneficially Form: 7.
Transaction Date, if Transaction (Instr. 3, 4 and 5) Owned Follow- Direct Nature of
Date any Code ------------------------------- ing Reported (D) or Indirect
1. (Month/ (Month/ (Instr. 8) (A) Transaction(s) Indirect Beneficial
Title of Security Day/ Day/ ------------ Amount or Price (Instr. 3 (I) Ownership
(Instr. 3) Year) Year) Code V (D) and 4) (Instr.4) (Instr. 4)
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Common Stock 01/03/03 S 1,382,077 D $13.56 0 D
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(1) As a result of the conversion of Blue Cross & Blue Shield United of Wisconsin ("BCBSUW") from a Wisconsin service insurance
corporation to a Wisconsin stock insurance corporation, Cobalt Corporation became the owner of 100% of the issued and
outstanding common stock of BCBSUW and Wisconsin United for Health Foundation, Inc. ("Foundation") became the owner of 77.5%
of the issued and outstanding common stock of Cobalt Corporation. Consequently, Cobalt Corporation became a beneficial owner
and the Foundation became an indirect beneficial owner of the Common Stock owned by BCBSUW.
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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).
Persons who respond to the collection of information contained in this form are not required to respond (Over)
unless the form displays a currently valid OMB control number. SEC 1474 (9-02)
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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10.
9. Owner-
Number ship
of Deriv- Form
2. ative of
Conver- 5. 7. Secur- Deriv- 11.
sion Number of Title and Amount ities ative Nature
or 3A. Derivative 6. of Underlying 8. Benefi- Secur- of
Exer- Deemed 4. Securities Date Securities Price cially ity: In-
cise 3. Execu- Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of Owned Direct direct
Price Trans- tion action or Disposed Expiration Date ---------------- Deriv- Following (D) or Bene-
1. of action Date, Code of(D) (Month/Day/Year) Amount ative Reported In- ficial
Title of Deriv- Date if any (Instr. (Instr. 3, ---------------- or Secur- Trans- direct Owner-
Derivative ative (Month/ (Month/ 8) 4 and 5) Date Expira- Number ity action(s) (I) ship
Security Secur- Day/ Day/ ------ ------------ Exer- tion of (Instr (Instr (Instr (Instr
(Instr. 3) ity Year) Year) Code V (A) (D) cisable Date Title Shares 5) 4) 4) 4)
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Explanation of Responses:
BLUE CROSS & BLUE SHIELD UNITED OF WISCONSIN
** Intentional misstatements or omissions of facts constitute Federal
Criminal Violations. /s/ Gail L. Hanson 01/06/03
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See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). ** Signature of Reporting Person Date
Gail L. Hanson, Senior Vice President
Note: File three copies of this Form, one of which must be manually signed.
If space 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.
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