UNITED STATES SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, D.C. 20549
FORM 4
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
( ) Check this box if no longer subject to Section 16. Form 4 or
Form 5 obligations may continue. See Instructions 1(b).
1. Name and Address of Reporting Person:
Karla M. Violetto
1 S. - 484 Leahy Road
Oakbrook Terrace, Illinois 60181
U.S.A.
2. Issuer Name and Ticker or Trading Symbol:
American Country Holdings Inc.
ACHI
3. IRS or Social Security Number of Reporting Person (Voluntary):
4. Statement for Month/Year:
November 2000
5. If Amendment, Date of Original (Month/Year):
April 2000
6. Relationship of Reporting Person(s) to Issuer (Check all
applicable):
( ) Director ( ) 10% Owner (x) Officer (give title below)
( ) Other (specify below):
Vice President and Chief Financial Officer
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 Acquired,
Disposed of, or Beneficially Owned
<TABLE>
<CAPTION>
5. Amount of
2. Trans- Securities 6. Owner-
action 3. Trans- Beneficially ship Form:
1. Title of Date action 4. Securities Acquired Owned at End Direct (D) or 7. Nature of Indirect
Security (Month/ Code (A) or Disposed of (D) of Month Indirect (I) Beneficial Ownership
(Instr. 3) Day/Year) (Instr. 8) (Instr. 3, 4 and 5) (Instr. 3 and 4) (Instr. 4) (Instr. 4)
----------- --------- ---------- ---------------------- ---------------- ------------- ---------------------
Code V Amount (A)or(D) Price
---- - ------ -------- -----
<S> <C> <C> <C> <C> <C> <C> <C> <C> <C>
</TABLE>
No securities are beneficially owned
Table II -- Derivative Securities Acquired,
Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
<TABLE>
<CAPTION> 10.
9. Owner-
5. Number ship
Number of Deri- Form of
2. of Deriv- vative Deri- 11.
Conver- ative Securi- vative Nature
sion or Secur- ties Secur- of Indi-
1. Exer- 3. ities 7. 8. Benefi- ity: rect
Title of cise Trans- 4. Acquired 6. Title and Price cially Direct Benefi-
Deriv- Price action Trans- (A) or Date Exer- Amount of of Deriv- Owned at (D) or cial
ative of Date action Disposed cisable and Underlying ative End of Indirect Owner-
Security Deriv- (Month/ Code of (D) Expiration Securities Security Month (I) ship
(Instr. ative Day/ (Instr. (Instr. 3, Date(Month/ (Instr. 3 (Instr. (Instr. (Instr. (Instr.
3) Security Year) 8) 4 and 5) Day/Year) and 4) 5) 4) 4) 4)
-------- -------- ------- --------- ---------- ------------- ---------- -------- --------- -------- --------
Code V (A) (D) Date Expir- Amount or
---- - --- --- Exer- ation Number of
cisable Date Title Shares
------- ------ ----- ---------
<S> <C> <C> <C> <C><C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
Option 1,250 D
Option 3.25 11/14/00 A 11/14/00 11/13/05 Common 16,750 16,750 D
Stock
$.01
par
value
Option 5.00 11/14/00 A 11/14/02* 11/13/05 Common 12,000 12,000 D
Stock
$.01
par
value
</TABLE>
*These options vest one-third immediately, one-third in one year and
one-third in two years.
Explanation of Responses:
SIGNATURE OF REPORTING PERSON:
/s/ Karla M. Violetto
------------------------------
Karla M. Violetto
Dated: December 11, 2000
