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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)
Nagle Robert E. Superior National Insurance Group, Inc. (SNTL) Director 10% Owner
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- - ------------------------------------------------------------------------------------------- X Officer (give Other (specify
(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) 11/99 Senior Vice President, General
26641 Agoura Road Counsel and Secretary
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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
(Instr. 8) Owned at Direct Ownership
(Month/ end of (D) or (Instr. 4)
Day/ ------------------------------ Issuer's Indirect
Year) Amount (A) or Price Fiscal Year (I)
(D) (Instr. 3 (Instr. 4)
and 4)
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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)
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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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Call Option
(right to buy) $20.00(1) 11/22/99 D 17,920 11/22/99 None
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Put Option
(right to sell) $10.00(1) 11/22/99 D 21,108(2) 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 17,920 (1) 17,920 I By Trust
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Common Stock 3,188(2) (1) 3,188(2) D
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17,920(2) I By Trust
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Explanation of Responses:
(1)-(2): Please see attached sheet.
/s/ Robert E. Nagle 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).
Robert E. Nagle
Note: File three copies of this Form, one of which must be manually signed.
If space 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) On November 22, 1999, Mr. Nagle and a revocable trust of which he is
trustee 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. Nagle purchased 17,920 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. Nagle and the Company have agreed, contingent upon Mr.
Nagle'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 but 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.
Nagle the right to cause the Company to purchase his collateral. In
addition, Mr. Nagle has agreed (i) to a maximum gain of $3.25 per share on
the sale of the 17,920 shares of Common Stock (treated as a "Call Option"
for reporting purposes, although the Company has no right to compel Mr.
Nagle 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. Nagle might obtain, and (iii) to consent to a 5% reduction in
his base salary.
(2) Includes in total (i) 17,920 shares of Common Stock which Mr. Nagle,
through a revocable trust, purchased with the note in November 1998, (ii)
1,328 shares of Common Stock owned by Mr. Nagle directly and pledged as
additional collateral, and (iii) options to purchase 1,860 shares of
Common Stock, all pledged as collateral for the note.
