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SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, D.C. 20549
FORM 15
Certification and Notice of Termination of Registration under Section 12(g) of
the Securities and Exchange Act of 1934 or Suspension of Duty to File Reports
Under Sections 13 and 15(d) of the Securities Exchange Act of 1934
COMMISSION FILE NUMBER 1-12251
AMERISAFE, INC.
(Exact name of registrant as specified in its charter)
2301 HIGHWAY 190 WEST
DERIDDER, LOUISIANA 70634
(318) 463-9052
(Address, including zip code, and telephone number, including
area code, of registrant's principal executive offices)
CLASS A COMMON STOCK,
PAR VALUE $.01 PER SHARE
(Title of each class of securities covered by this Form)
NONE
(Title of all other classes of securities for which a duty to
file reports under Section 13(a) or 15(d) remains)
Please place an X in the box(es) to designate the appropriate rule
provision(s) relied upon to terminate or suspend the duty to file reports:
Rule 12g-4(a)(1)(i) [X] Rule 12h-3(b)(1)(i) [X]
Rule 12g-4(a)(1)(ii) [ ] Rule 12h-3(b)(1)(ii) [ ]
Rule 12g-4(a)(2)(i) [ ] Rule 12h-3(b)(2)(i) [ ]
Rule 12g-4(a)(2)(ii) [ ] Rule 12h-3(b)(2)(ii) [ ]
Rule 15d-6 [ ]
Number of holders of record as of the certification or notice date:
none (0)
Signature
Pursuant to the requirements of the Securities Exchange Act of 1934,
AMERISAFE, Inc. has caused this certification/notice to be signed on its behalf
by the undersigned duly authorized person.
Date: November 5, 1996 AMERISAFE, INC.
By: /s/ ARTHUR L. HUNT
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Arthur L. Hunt, Vice President
