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- - -------- UNITED STATES SECURITIES AND EXCHANGE COMMISSION -----------------------------
FORM 5 WASHINGTON, D.C. 20549 OMB APPROVAL
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/ / CHECK BOX IF NO LONGER ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OMB NUMBER: 3235-0362
SUBJECT TO SECTION 16. EXPIRES: SEPTEMBER 30, 1998
FORM 4 OR FORM 5 OBLI- Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, ESTIMATED AVERAGE BURDEN
GATIONS MAY CONTINUE. Section 17(a) of the Public Utility Holding Company Act of 1935 or HOURS PER RESPONSE .... 1.0
SEE INSTRUCTION 1(b). Section 30(f) of the Investment Company Act of 1940 -----------------------------
/ / FORM 3 HOLDINGS REPORTED
/ / FORM 4 TRANSACTIONS REPORTED
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1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person(s)
to Issuer (Check all applicable)
X Director 10% Owner
Seaman J. Chris Superior National Insurance Group, Inc. (SNTL) ---- ----
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(Last) (First) (Middle) 3. IRS or Social Security 4. Statement for ---- title ---- below)
Number of Reporting Month/Year below)
c/o Superior National Insurance Group, Inc. Person (Voluntary) President and Chief Executive Officer
26541 Agoura Road 02/00 -------------------------------------
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(Street) 5. If Amendment, 7. Individual or Joint/Group Reporting
Date of Original (check applicable line)
(Month/Year) X Form Filed by One Reporting Person
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Form filed by More than One
Reporting Person
Calabasas CA 91302 ---
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(City) (State) (Zip) TABLE I -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
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1. Title of Security 2. Trans- 3. Transac- 4. Securities Acquired (A) or 5. Amount of 6. Owner- 7. Nature of
(Instr. 3) action tion Disposed of (D) Securities ship Indirect
Date Code (Instr. 3, 4 and 5) Beneficially Form: Beneficial
(Month/ (Instr. 8) Owned at Direct Ownership
Day/ end of (D) or (Instr. 4)
Year) ------------------------------ Issuer's Indirect
Amount (A) or Price Fiscal Year (I)
(D) (Instr. 3 (Instr. 4)
and 4)
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Common Stock 2/16/99 A(1) 7,284 A $19.375 267,907 D
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*If the form is filed by more than one reporting person, see instruction 4(b)(v). (Over)
SEC 2270 (7/97)
POTENTIAL PERSONS WHO ARE TO RESPOND TO THE COLLECTION OF INFORMATION
CONTAINED IN THIS FORM ARE NOT REQUIRED TO RESPOND UNLESS THE FORM DISPLAYS
A CURRENTLY VALID OMB CONTROL NUMBER.
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FORM 5 (CONTINUED) TABLE II - DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
(e.g., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
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1. Title of Derivative Security 2. Conver- 3. Trans- 4. Trans- 5. Number of 6. Date Exer-
(Instr. 3) sion of action action Derivative cisable and
Exercise Date Code Securities Ac- Expiration
Price of (Month/ (Instr. 8) quired (A) or Date
Deriv- Day/ Disposed of Month/Day/
ative Year) (D) Year)
Security (Instr. 3, 4, and 5)
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Date Expir-
---------------------- Exer- ation
cisable Date
(A) (D)
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Employee Stock Option (Right to Buy) $19.375 2/16/99 A V 14,569 (3) 2/15/09
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Call Option (right to buy) $20.00(1) 11/22/99 D 193,828 11/22/99 None
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Put Option (right to sell) $10.00(1) 11/22/99 D 394,840(5) 11/30/02 None
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7. Title and Amount of Under- 8. Price 9. Number 10. Owner- 11. Na-
lying Securities of of Deriv- ship ture of
(Instr. 3 and 4) Deriv- ative of Indirect
ative Secur- Deriv- Bene-
Secur- ities ative ficial
ity Bene- Secur- Owner-
(Instr. ficially ity: ship
5) Owned Direct (Instr. 4)
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of Year or In-
Amount or (Instr. 4) direct
Title Number of (I)
Shares (Instr. 4)
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Common Stock 14,569 14,569 D
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Common Stock 193,828 (4) 193,828 D
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Common Stock 394,840(5) (4) 394,840(5) D
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Explanation of Responses:
(1)-(5) Please see attached sheet.
/s J. Chris Seaman 02/11/00
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**Intentional misstatements or omissions of facts constitute **Signature of Reporting Person Date
Federal Criminal Violations. SEE 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
J. Chris Seaman
Note: File three copies of this Form, one of which must be manually signed.
If space provided is insufficient, SEE Instruction 6 for procedure.
Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the
form displays a currently valid OMB number. Page 2
SEC 2270 (7-97)
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(1) The reported security represents a grant of restricted stock pursuant to
the Company's 1995 Stock Incentive Plan.
(2) Includes 19,997 shares of restricted stock subject to the Company's
right to repurchase as of the date hereof.
(3) The reported security represents stock options granted pursuant to the
Company's 1995 Stock Incentive Plan that vest in equal annual increments
of 20% over a five-year period following their date of grant, February
16, 1999.
(4) On November 22, 1999, Mr. Seaman entered into an Amendment Agreement
(the "Amendment") with Superior National Insurance Group, Inc. (the
"Company") whereby the parties amended the terms of a promissory note
and a pledge agreement pursuant to which Mr. Seaman purchased 193,828
shares of Company Common Stock on November 20, 1998 at $16.75 per share.
The Board of Directors approved the Amendment Agreement on November 16,
1999. Pursuant to the Amendment, Mr. Seaman and the Company have agreed,
contingent upon Mr. Seaman's continuing in employment for three (3)
years, or upon the occurrence of certain other events, to treat the
collateral pledged under the pledge agreement as having a minimum value
of $10.00 per common share. Thus, if there is a foreclosure on the
pledge, the maximum loss per share of stock purchased with the note in
November 1998 would be $6.75, plus accrued and unpaid interest on the
note. This agreement is treated as a "put option" under Section 16 of
the Securities Exchange Act, although nothing under the terms of the
Amendment could be construed as giving Mr. Seaman the right to cause the
Company to purchase his collateral. In addition, Mr. Seaman has agreed
(i) to a maximum gain of $3.25 per share on the sale of 193,828 shares
of Common Stock (treated as a "Call Option" for reporting purposes,
although the Company has no right to compel Mr. Seaman to sell his
shares to the Company), with any additional gain for the benefit of the
Company, (ii) to provide the Company with additional collateral on the
note in the form of offset rights against any severance benefits Mr.
Seaman might obtain, and (iii) to consent to a 5% reduction in his base
salary.
(5) Includes in total (i) 193,828 shares of Common Stock Mr. Seaman
purchased with the note in November 1998, (ii) 74,079 shares of Common
Stock Mr. Seaman has pledged as additional collateral, and (iii) options
to purchase 126,933 shares of Common Stock, all pledged as collateral
for the note.
