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