WASHINGTON, D.C. 20549
FORM 3
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
1. Name and Address of Reporting Person:
Daniel R. DeLeo
6 North 415 River Grange Road
St. Charles, IL 60174
2. Date of Event Requiring Statement (Month/Day/Year)
November, 2000
3. I.R.S. Identification Number of Reporting Person, if an entity
(Voluntary):
4. Issuer Name and Ticker of Trading Symbol:
American Country Holdings Inc.
ACHI
5. Relationship of Reporting Person(s) to Issuer (Check all
applicable):
( ) Director
(x) Officer (give title below)
( ) 10% Owner
( ) Other (specify below)
Executive Vice President
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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>
<CAPTION>
TABLE I - NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED
2. Amount of Securities 3. Ownership Form: 4. Nature of Indirect
1. Title of Security Beneficially Owned (Inst. Direct (D) or Indirect Beneficial Ownership
(Instr. 4) 4) (I) (Instr. 5) (Instr. 5)
-------------------- ------------------------- ---------------------- ---------------------
<S> <C> <C> <C>
Common Stock, 463 D
$.01 par value
</TABLE>
<TABLE>
<CAPTION>
TABLE II - DERIVATIVE SECURITIES BENEFICIALLY OWNED (E.G., PUTS,
CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
5.
Ownership
Form of
4. Conver- Derivative
sion or Security: 6. Nature
1. Title of 3. Title and Amount of Exercise Direct (D) of Indirect
Derivative 2. Date Exercisable Securities Underlying Price of or Indi- Beneficial
Security and Expiration Date Derivative Security Derivative rect (I) Ownership
(Instr. 4) (Month/Day/Year) (Instr. 4) Security (Instr. 5) (Instr. 5)
----------- ------------------- ------------------- ---------- ----------- ----------
Date Amount or
Exer- Expira- Number of
cisable tion Date Title Shares
-------- -------- ------ ---------
<S> <C> <C> <C> <C> <C> <C> <C>
Option Common Stock, 7,232 D
$.01 par value
Option 11/14/00 11/13/05 Common Stock, 35,000 $3.25 D
$.01 par value
Option 11/14/02* 11/13/05 Common Stock, 25,000 $5.00 D
$.01 par value
*These options vest 1/3% immediately, 1/3 in one year and 1/3 in two years.
</TABLE>
SIGNATURE OF REPORTING PERSON:
/s/ Daniel R. DeLeo
-----------------------
Daniel R. DeLeo
Dated: December 8, 2000
