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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
Persons who 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. | SEC 1474 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Warrant Shares | $ 16.67 (3) | (4) | 01/03/2012 | Common Shares | 7,172,357.5 | 7,172,357.5 | I | By wholly-owned subsidiaries of White Mountains Insurance Group, Ltd. See Footnote 5. (5) |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
WHITE MOUNTAINS INSURANCE GROUP LTD 80 SOUTH MAIN STREET HANOVER, NH 03755 |
X |
Dennis Beaulieu, Corporate Secretary, White Mountains Insurance Group, Ltd. | 11/03/2004 | |
**Signature of Reporting Person | Date | |
Dennis Beaulieu, by Power of Attorney on behalf of Folksamerica Reinsurance Company | 11/03/2004 | |
**Signature of Reporting Person | Date | |
Dennis Beaulieu, by Power of Attorney on behalf of The Camden Fire Insurance Association, OneBeacon Insurance Company, and Pennsylvania General Insurance Company | 11/03/2004 | |
**Signature of Reporting Person | Date | |
Dennis Beaulieu, by Power of Attorney on behalf of WM Asset Management (Barbados) Ltd. | 11/03/2004 | |
**Signature of Reporting Person | Date | |
Dennis Beaulieu, by Power of Attorney on behalf of Sirius International Insurance Corporation | 11/03/2004 | |
**Signature of Reporting Person | Date | |
Dennis Beaulieu, on behalf of White Mountains Financial Services Ltd. | 11/03/2004 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(b)(v). |
** | Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
(1) | Pro rata distribution from Century Capital Partners LP, of which Folksamerica Reinsurance Company, an indirect wholly-owned subsidiary of White Mountains Insurance Group, Ltd., is a limited partner. |
(2) | Folksamerica Reinsurance Company, OneBeacon Insurance Company, The Camden Fire Insurance Association, and Pennsylvania General Insurance Company are indirect wholly-owned subsidiaries of White Mountains Insurance Group, Ltd. |
(3) | Warrants Shares are exercisable for Common Shares on a 1 for 1 basis at an exercise price of $16.67 per Warrant Share. |
(4) | Currently exercisable. |
(5) | Warrant Shares are held by Folksamerica Reinsurance Company, WM Asset Management (Barbados) Ltd., Sirius International Insurance Corporation and White Mountains Financial Services Ltd., each an indirect wholly-owned subsidiary of White Mountains Insurance Group, Ltd. |