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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)
Boggs, Jr. Thomas. I. Superior National Insurance Group, Inc. (SNTL) Director 10% Owner
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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) 02/00 Senior Vice President and Chief
26541 Agoura Road Underwriting Officer
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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
---
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)
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 $19,375 2/16/99 A 3,750 (1) 2/15/09
buy)
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Call Option
(right to buy) $20.00(2) 11/22/99 D 35,191 11/22/99 None
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Put Option
(right to sell) $10.00(2) 11/22/99 D 68,161(3) 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 3,750 3,750 D
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Common Stock 35,191 (2) 35,191 D
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Common Stock 68,161(3) (2) 68,161(3) D
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Explanation of Responses:
(1)-(3) Please see attached sheet.
/s/ Thomas I. Boggs, Jr. 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).
Thomas I. Boggs, Jr.
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 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.
(2) On November 22, 1999, Mr. Boggs 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. Boggs purchased 35,191 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. Boggs and the Company have agreed, contingent upon
Mr. Boggs'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.
Boggs the right to cause the Company to purchase his collateral. In
addition, Mr. Boggs has agreed (i) to a maximum gain of $3.25 per share on
the sale of the 35,191 shares of Common Stock (treated as a "Call Option"
for reporting purposes, although the Company has no right to compel Mr.
Boggs 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. Boggs might obtain, and (iii) to consent to a 5% reduction in
his base salary.
(3) Includes in total (i) 35,191 shares of Common Stock Mr. Boggs purchased
with the note in November 1998, (ii) 12,695 shares of Common Stock Mr.
Boggs has pledged as additional collateral, and (iii) options to purchase
20,275 shares of Common Stock, all pledged as collateral for the note.
