------------------------------
OMB APPROVAL
------------------------------
OMB Number
Expires:
Estimated average burden
hours per response ....... 1.0
------------------------------
U.S. SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 5
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
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(f) of the Investment Company Act of 1940
[_] Check box if no longer subject to Section 16. Form 4 or Form 5 obligations
may continue. See Instruction 1(b).
[_] Form 3 Holdings Reported
[_] Form 4 Transactions Reported
________________________________________________________________________________
1. Name and Address of Reporting Person*
Thompson Scott G.
- --------------------------------------------------------------------------------
(Last) (First) (Middle)
421 Hollydale Court
- --------------------------------------------------------------------------------
(Street)
Atlanta Georgia 30342-3631
- --------------------------------------------------------------------------------
(City) (State) (Zip)
________________________________________________________________________________
2. Issuer Name and Ticker or Trading Symbol
Atlantic American Corporation - AAME
________________________________________________________________________________
3. IRS Identification Number of Reporting Person, if an Entity (Voluntary)
________________________________________________________________________________
4. Statement for Month/Year
December, 2001
________________________________________________________________________________
5. If Amendment, Date of Original (Month/Year)
________________________________________________________________________________
6. Relationship of Reporting Person to Issuer
(Check all applicable)
[X] Director [ ] 10% Owner
[X] Officer (give title below) [ ] Other (specify below)
President & CFO of Subsidiary - American Southern Insurance Company
________________________________________________________________________________
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
================================================================================
5. 6.
4. Amount of Owner-
Securities Acquired (A) or Securities ship
Disposed of (D) Beneficially Form: 7.
(Instr. 3, 4 and 5) Owned at End Direct Nature of
2. 3. ----------------------------- of Issuer's (D) or Indirect
1. Transaction Transaction (A) Fiscal Year Indirect Beneficial
Title of Security Date Code Amount or Price (Instr. 3 (I) Ownership
(Instr. 3) (mm/dd/yy) (Instr. 8) (D) and 4) (Instr.4) (Instr. 4)
- ------------------------------------------------------------------------------------------------------------------------------------
Common Stock N/A 1,000 D
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
====================================================================================================================================
* If the form is filed by more than one Reporting Person, see Instruction
4(b)(v).
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
(Over)
(Form 5-07/98)
FORM 5 (continued)
Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
================================================================================
9. 10.
Number Owner-
of ship
2. Deriv- of
Conver- 5. 7. ative Deriv- 11.
sion Number of Title and Amount Secur- ative Nature
or Derivative 6. of Underlying 8. ities Secur- of
Exer- Securities Date Securities Price Bene- ity: In-
cise 3. Acquired (A) Exercisable and (Instr. 3 and 4) of ficially Direct direct
Price Trans- 4. or Disposed Expiration Date ---------------- Deriv- Owned (D) or Bene-
1. of action Trans- of (D) (Month/Day/Year) Amount ative at End In- ficial
Title of Deriv- Date action (Instr. 3, ---------------- or Secur- of direct Owner-
Derivative ative (Month/ Code 4 and 5) Date Expira- Number ity Year (I) ship
Security Secur- Day/ (Instr. ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr.
(Instr. 3) ity Year) 8) (A) (D) cisable Date Title Shares 5) 4) 4) 4)
- ------------------------------------------------------------------------------------------------------------------------------------
Employee Stock
Option(1) $1.25 10/15/01 A 32,500 10/15/01 10/15/11 Cmn. Stk. 32,500 D
- ------------------------------------------------------------------------------------------------------------------------------------
Employee Stock
Option(1) $1.25 10/15/01 A 16,250 10/15/02 10/15/11 Cmn. Stk. 16,250 D
- ------------------------------------------------------------------------------------------------------------------------------------
Employee Stock
Option(1) $1.25 10/15/01 A 16,250 10/15/03 10/15/11 Cmn. Stk. 16,250 90,000(2) D
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
- ------------------------------------------------------------------------------------------------------------------------------------
====================================================================================================================================
Explanation of Responses:
1 Option to buy 65,000 shares Common Stock, exempt under Rule 16b-3, of which
50% were exercisable on 10/15/01; an additional 25% are excercisable 10/15/02;
and the remaining 25% are exercisable on 10/15/03. These options are granted
under the Atlantic American Corporation 1992 Incentive Plan.
2 Options to buy Common Stock granted pursuant to the Company's 1992 Incentive
Plan at prices ranging from $1.25 to $3.75.
02/12/02
- --------------------------------------------- -----------------------
Scott G. Thompson Date
**Signature of Reporting Person
** Intentional misstatements or omissions of facts constitute Federal Criminal
Violations.
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
Note: File three copies of this form, one of which must be manually signed.
If space provided is insufficient, see Instruction 6 for procedure.
Page 2
