SC 13G 1 s13g_0124-2006amerisafe.txt SCHEDULE 13G CUSIP No. 03071H 10 0 Page 1 of 9 Pages SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 ------------------- 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. ------------------------------------------------------------------------------- (Name of Issuer) Common Stock, $.01 par value ------------------------------------------------------------------------------- (Title of Class of Securities) 03071H 10 0 ------------------------------------------------------------------------------- (CUSIP Number) November 17, 2005 ------------------------------------------------------------------------------- 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) ------------------------------------------------------------------------------- 2) Check the Appropriate Box (a) [X] if a Member of a Group (b) [ ] ------------------------------------------------------------------------------- 3) SEC Use Only ------------------------------------------------------------------------------- 4) Citizenship or Place Delaware of Organization ------------------------------------------------------------------------------- Number of 5) Sole Voting 7,636,475 shares Shares Beneficially Power of Common Stock Owned by Each Reporting Person With ------------------------------------------------- 6) Shared Voting Power -0- ------------------------------------------------- 7) Sole Disposi- 7,636,475 shares tive Power of Common Stock ------------------------------------------------- 8) Shared Dis- positive Power -0- ------------------------------------------------- 9) Aggregate Amount Beneficially 7,636,475 shares Owned by Each Reporting person of Common Stock ------------------------------------------------------------------------------- 10) Check if the Aggregate Amount in Row (9) Excludes Certain Shares ------------------------------------------------------------------------------- 11) Percent of Class Represented by 43.8% Amount in Row (9) ------------------------------------------------------------------------------- 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) ------------------------------------------------------------------------------- 2) Check the Appropriate Box (a) [X] if a Member of a Group (b) [ ] ------------------------------------------------------------------------------- 3) SEC Use Only ------------------------------------------------------------------------------- 4) Citizenship or Place Delaware of Organization ------------------------------------------------------------------------------- Number of 5) Sole Voting 61,020 shares Shares Beneficially Power of Common Stock Owned by Each Reporting Person With ------------------------------------------------- 6) Shared Voting Power -0- ------------------------------------------------- 7) Sole Disposi- 61,020 shares tive Power of Common Stock ------------------------------------------------- 8) Shared Dis- positive Power -0- ------------------------------------------------- 9) Aggregate Amount Beneficially 61,020 shares Owned by Each Reporting person of Common Stock ------------------------------------------------------------------------------- 10) Check if the Aggregate Amount in Row (9) Excludes Certain Shares ------------------------------------------------------------------------------- 11) Percent of Class Represented by 0.4% Amount in Row (9) ------------------------------------------------------------------------------- 12) Type of Reporting Person PN CUSIP No. 03071H 10 0 Page 4 of 9 Pages Schedule 13G ------------ 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 --------------------------------------------- General Partner WCAS HEALTHCARE PARTNERS, L.P. By: WCAS HP Partners, General Partner By /s/ Jonathan M. Rather --------------------------------------------- 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) ------------------------- 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 --------------------------------------------- General Partner WCAS HEALTHCARE PARTNERS, L.P. By: WCAS HP Partners, General Partner By /s/ Jonathan M. Rather --------------------------------------------- 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 ----------------------- 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.