U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, DC 20549
FORM 3
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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(f) of the Investment Company Act of 1940
--------------------------------------------------------------------------------
1. Name and Address of Reporting Person*
Prochnow James E.
--------------------------------------------------------------------------------
(Last) (First) (Middle)
3100 AMS Boulevard
--------------------------------------------------------------------------------
(Street)
Green Bay WI 54313
--------------------------------------------------------------------------------
(City) (State) (Zip)
--------------------------------------------------------------------------------
2. Date of Event Requiring Statement (Month/Day/Year)
12/31/2002 (1)
--------------------------------------------------------------------------------
3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
--------------------------------------------------------------------------------
4. Issuer Name and Ticker or Trading Symbol
American Medical Security Group, Inc. (AMZ)
--------------------------------------------------------------------------------
5. Relationship of Reporting Person to Issuer
(Check all applicable)
[_] Director [_] 10% Owner
[x] Officer (give title below) [_] Other (specify below)
Vice President, Controller and Interim Treasurer
--------------------------------------------------------------------------------
6. If Amendment, Date of Original (Month/Day/Year)
--------------------------------------------------------------------------------
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 Beneficially Owned
================================================================================
3. Ownership Form:
2. Amount of Securities Direct (D) or
1. Title of Security Beneficially Owned Indirect (I) 4. Nature of Indirect Beneficial Ownership
(Instr. 4) (Instr. 4) (Instr. 5) (Instr. 4)
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
No securities owned
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
====================================================================================================================================
(1) Section 16(a) reports were filed for Mr. Prochnow from 1998 until early
2000 at which time the Board of Directors of AMZ determined he was not an
officer as defined in Section 16a-1(f); and, therefore, Mr. Prochnow ceased
filing Section 16a reports. No Section 16a reports were filed to indicate
he exited the reporting system. On 12/31/02 he became a Section 16 officer
which prompted the filing of this Form 3.
* If the Form is filed by more than one Reporting Person, see Instruction
5(b)(v).
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
(Print of Type Responses)
(Over)
FORM 3 (continued)
Table II -- Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
================================================================================
5. Owner-
3. Title and Amount of Securities ship
Underlying Derivative Security Form of
2. Date Exercisable (Instr. 4) Derivative
and Expiration Date --------------------------------- 4. Conver- Security:
(Month/Day/Year) Amount sion or Direct 6. Nature of
---------------------- or Exercise (D) or Indirect
Date Expira- Number Price of Indirect Beneficial
1. Title of Derivative Exer- tion of Derivative (I) Ownership
Security (Instr. 4) cisable Date Title Shares Security (Instr. 5) (Instr. 5)
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
Employee Stock Option (2) 12/17/10 Common Stock 5,000 $14.3750 D
(right to buy)
------------------------------------------------------------------------------------------------------------------------------------
Employee Stock Option (3) 11/16/11 Common Stock 5,000 $ 5.8125 D
(right to buy)
------------------------------------------------------------------------------------------------------------------------------------
Employee Stock Option (4) 11/16/12 Common Stock 10,000 $ 5.1875 D
(right to buy)
------------------------------------------------------------------------------------------------------------------------------------
Employee Stock Option (5) 11/28/13 Common Stock 10,000 $10.2000 D
(right to buy)
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
====================================================================================================================================
Explanation of Responses:
(2)The option becomes exercisable in four annual installments beginning 12/18/99
(3)The option becomes exercisable in four annual installments beginning 11/17/00
(4)The option becomes exercisable in four annual installments beginning 11/17/01
(5)The option becomes exercisable in four annual installments beginning 11/29/02
/s/ James E. Prochnow 1/9/03
--------------------------------------------- -----------------------
**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.
(Print or Type Responses)
Page 2