CUSIP No. 03071H 10 0 Page 1 of 9 Pages
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
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SCHEDULE 13G
(Rule 13d-102)
INFORMATION TO BE INCLUDED IN STATEMENTS FILES PURSUANT
TO RULES 13d-1(b),(c), AND (d) AND AMENDMENTS THERETO FILED
PURSUANT TO RULE 13d-2(b)
(Amendment No. )
Amerisafe, Inc.
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(Name of Issuer)
Common Stock, $.01 par value
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(Title of Class of Securities)
03071H 10 0
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(CUSIP Number)
November 17, 2005
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Date of Event Which Requires Filing of this Statement
Check the appropriate box to designate the rule pursuant to which this Schedule
is Filed:
[ ] Rule 13d-1(b)
[ ] Rule 13d-1(c)
[X] Rule 13d-1(d)
CUSIP No. 03071H 10 0 Page 2 of 9 Pages
1) Name of Reporting Person Welsh, Carson,
I.R.S. Identification Anderson & Stowe
No. of Above Person VII, L.P.
(Entities Only)
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2) Check the Appropriate Box (a) [X]
if a Member of a Group (b) [ ]
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3) SEC Use Only
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4) Citizenship or Place Delaware
of Organization
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Number of 5) Sole Voting 7,636,475 shares
Shares Beneficially Power of Common Stock
Owned by Each
Reporting Person
With
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6) Shared Voting
Power -0-
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7) Sole Disposi- 7,636,475 shares
tive Power of Common Stock
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8) Shared Dis-
positive Power -0-
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9) Aggregate Amount Beneficially 7,636,475 shares
Owned by Each Reporting person of Common Stock
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10) Check if the Aggregate
Amount in Row (9)
Excludes Certain Shares
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11) Percent of Class
Represented by 43.8%
Amount in Row (9)
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12) Type of Reporting
Person PN
CUSIP No. 03071H 10 0 Page 3 of 9 Pages
1) Name of Reporting Person WCAS Healthcare
I.R.S. Identification Partners, L.P.
No. of Above Person
(Entities Only)
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2) Check the Appropriate Box (a) [X]
if a Member of a Group (b) [ ]
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3) SEC Use Only
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4) Citizenship or Place Delaware
of Organization
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Number of 5) Sole Voting 61,020 shares
Shares Beneficially Power of Common Stock
Owned by Each
Reporting Person
With
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6) Shared Voting
Power -0-
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7) Sole Disposi- 61,020 shares
tive Power of Common Stock
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8) Shared Dis-
positive Power -0-
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9) Aggregate Amount Beneficially 61,020 shares
Owned by Each Reporting person of Common Stock
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10) Check if the Aggregate
Amount in Row (9)
Excludes Certain Shares
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11) Percent of Class
Represented by 0.4%
Amount in Row (9)
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12) Type of Reporting
Person PN
CUSIP No. 03071H 10 0 Page 4 of 9 Pages
Schedule 13G
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Item 1(a) - Name of Issuer: Amerisafe, Inc.
Item 1(b) - Address of Issuer's Principal Executive Offices:
2301 Highway 190 West
DeRidder, Louisiana 70634
Item 2(a) - Name of Person Filing:
This statement is being filed by Welsh, Carson, Anderson &
Stowe VII, L.P., a Delaware limited partnership ("WCAS VII"),
and WCAS Healthcare Partners, L.P., a Delaware limited
partnership ("WCAS HP") (together, the "Reporting Persons").
Item 2(b) - Address of Principal Business Office:
320 Park Avenue, Suite 2500
New York, NY 10022
Item 2(c) - Place of Organization:
WCAS VII: Delaware
WCAS HP: Delaware
Item 2(d) - Title of Class of Securities:
Common Stock, $.01 par value
Item 2(e) - CUSIP Number: 03071H 10 0
Item 3 - Statements Filed Pursuant to Rules 13d-1(b) or 13d-2(b):
Not applicable.
Item 4 - Ownership.
(a) Amount Beneficially Owned:
WCAS VII: 7,636,475 shares of Common Stock
WCAS HP: 61,020 shares of Common Stock
CUSIP No. 03071H 10 0 Page 5 of 9 Pages
(b) Percent of Class:
WCAS VII: 43.8%
WCAS HP: 0.4%
(c) Number of shares as to which such person has:
(i) sole power to vote or to direct the vote:
WCAS VII: 7,636,475 shares of Common Stock
WCAS HP: 61,020 shares of Common Stock
(ii) shared power to vote or to direct the vote:
-0-
(iii) sole power to dispose or to direct the disposition of:
WCAS VII: 7,636,475 shares of Common Stock
WCAS HP: 61,020 shares of Common Stock
(iv) shared power to dispose or to direct the disposition of:
-0-
Item 5 - Ownership of Five Percent or Less of a Class:
Not applicable.
Item 6 - Ownership of More than Five Percent on Behalf of Another
Person:
Not applicable.
Item 7 - Identification and Classification of the Subsidiary Which
Acquired the Security Being Reported on by the Parent Company:
Not applicable.
Item 8 - Identification and Classification of Members of the Group:
See Exhibit 2.
CUSIP No. 03071H 10 0 Page 6 of 9 Pages
Item 9 - Notice of Dissolution of Group:
Not applicable.
Item 10 - Certification:
Not applicable.
CUSIP No. 03071H 10 0 Page 7 of 9 Pages
Signature:
After reasonable inquiry and to the best of their knowledge and
belief, the undersigned certify that the information set forth in this statement
is true, complete and correct.
WELSH, CARSON, ANDERSON & STOWE VII, L.P.
By: WCAS VII Partners, L.P., General Partner
By /s/ Jonathan M. Rather
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General Partner
WCAS HEALTHCARE PARTNERS, L.P.
By: WCAS HP Partners, General Partner
By /s/ Jonathan M. Rather
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Attorney-in-Fact
Date: January 18, 2006
CUSIP No. 03071H 10 0 Page 8 of 9 Pages
EXHIBIT 1
AGREEMENT OF
WELSH, CARSON, ANDERSON & STOWE VII, L.P.
AND
WCAS HEALTHCARE PARTNERS, L.P.
PURSUANT TO RULE 13d-1(f)
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The undersigned hereby agree that the Information Statement on
Schedule 13G to which this Agreement is annexed as Exhibit 1 is filed on behalf
of each of them in accordance with provisions of 13d-1(f) under the Securities
Exchange Act of 1934, as amended.
WELSH, CARSON, ANDERSON & STOWE VII, L.P.
By: WCAS VII Partners, L.P., General Partner
By /s/ Jonathan M. Rather
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General Partner
WCAS HEALTHCARE PARTNERS, L.P.
By: WCAS HP Partners, General Partner
By /s/ Jonathan M. Rather
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Attorney-in-Fact
Date: January 18, 2006
CUSIP No. 03071H 10 0 Page 9 of 9 Pages
Identification and Classification
of Members of the Group
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Welsh, Carson, Anderson & Stowe VII, L.P and WCAS Healthcare Partners,
L.P. are filing this statement on Schedule 13G as a group.
Welsh, Carson, Anderson & Stowe VII, L.P is a Delaware limited
partnership. Its sole general partner is WCAS VII Partners, L.P., a Delaware
limited partnership.
WCAS Healthcare Partners, L.P. is a Delaware limited partnership. Its
sole general partner is WCAS HP Partners, a Delaware general partnership.