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SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
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FORM 8-A
FOR REGISTRATION OF CERTAIN CLASSES OF
SECURITIES PURSUANT TO SECTION 12(b) or (g)
OF THE SECURITIES EXCHANGE ACT OF 1934
AMERISAFE, INC.
(Exact name of Registrant as specified in its charter)
TEXAS 75-2069407
(State of incorporation (I.R.S. Employer
or organization) Identification No.)
2301 HIGHWAY 190 WEST, DERIDDER, LOUISIANA 70634
(Address of principal executive offices) (Zip Code)
If this form relates to the If this form relates to the
registration of a class of debt registration of a class of debt
securities and is effective upon securities and is to become effective
filing pursuant to General Instruction simultaneously with the effectiveness
A(c)(1) please check the following of a concurrent registration statement
box. [ ] under the Securities Act of 1933
pursuant to General Instruction
A(c)(2) please check the following
box. [ ]
SECURITIES TO BE REGISTERED PURSUANT TO SECTION 12(B) OF THE ACT:
TITLE OF EACH CLASS NAME OF EACH EXCHANGE ON WHICH
TO BE SO REGISTERED EACH CLASS IS TO BE REGISTERED
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Class A Common Stock, New York Stock Exchange
par value $.01 per share
SECURITIES TO BE REGISTERED PURSUANT TO SECTION 12(G) OF THE ACT:
Not applicable
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ITEM 1. DESCRIPTION OF REGISTRANT'S SECURITIES TO BE REGISTERED.
The description of the Class A Common Stock, $.01 par value per share
(the "Common Stock"), of AMERISAFE, Inc. (the "Company") set forth
under the caption "Description of Capital Stock" in Amendment No. 1 to
the Registration Statement on Form S-1 (Commission File No. 333-10099),
filed by the Company with the Securities and Exchange Commission on
September 25, 1996, including exhibits, is hereby incorporated by
reference.
ITEM 2. EXHIBITS.
All exhibits required by Instruction II to Item 2 will be filed with the
New York Stock Exchange.
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SIGNATURE
Pursuant to the requirements of Section 12 of the Securities Exchange
Act of 1934, the registrant has duly caused this registration statement to be
signed on its behalf by the undersigned, thereunto duly authorized.
AMERISAFE, INC.
Date: September 27, 1996 By: /s/ ARTHUR L. HUNT
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Arthur L. Hunt
Vice President
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