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:
John A. Dore
222 N. LaSalle, Ste. 1600
Chicago, Illinois 60601
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):
September 2000
6. Relationship of Reporting Person(s) to Issuer (Check all
applicable):
(x) Director ( ) 10% Owner (x) Officer (give title below)
( ) Other (specify below):
Co-Chairman of the Board, Director and Chief Executive
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>
Common Stock, 161,000 D
$.01 par value
Common Stock 2,000 I IRA
$.01 par value
Common Stock, 4,000 I Keough
$.01 par value
Common Stock 2,600 I As trustee
$.01 par value for Christopher L. Dore
Common Stock 3,565 I As trustee for
$.01 par value John A. Dore II
</TABLE>
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- 8. ties Secur- of Indi-
1. Exer- 3. ities 7. 8. Benefi- ity: rect
Title of cise Trans- Acquired 6. Title and Price cially Direct Benefi-
Deriv- Price action 4. (A) or Date Exer- Amount of of Deriv- Owned at (D) or cial
at1ive of Date Trans- Disposed cisable and Underlying ative End of Indirect Owner-
Security Deriv- (Month/ action of (D) Expiration Securities Security Month (I) ship
(Instr. ative Day/ Code (Instr. 3, Date(Month/ (Instr. 3 (Instr. (Instr. (Instr. (Instr.
3) Security Year) (Instr. 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 2.88 11/10/00 D 100,000* Common 100,000 200,000 D
Stock
$.01 par
value
</TABLE>
*Voluntarily surrendered to Company.
Explanation of Responses:
SIGNATURE OF REPORTING PERSON:
/s/ John A. Dore
------------------------------
John A. Dore
Dated: December 8, 2000
