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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 | ||||||||
| Common Stock Purchase Warrants | (5) | 09/30/2008 | J | 164,494 | (5) | (5) | Common Stock | 164,494 | (5) | 164,494 | D | ||||
| Common Stock Purchase Warrants | (5) | 09/30/2008 | J | 16,913 | (5) | (5) | Common Stock | 16,913 | (5) | 16,913 | I | By Greg Branch Family LP (4) | |||
| Common Stock Purchase Warrants | (5) | 09/30/2008 | J | 35,787 | (5) | (5) | Common Stock | 35,787 | (5) | 35,787 | I | By O.C. Branch Trust | |||
| Reporting Owner Name / Address | Relationships | |||
| Director | 10% Owner | Officer | Other | |
| Branch Gregory C 360 CENTRAL AVENUE SUITE 900 SAINT PETERBURG, FL 33701 |
X | Chairman of the Board | ||
| /s/ Carolyn T. Long as Attorney-in-Fact for Gregory C. Branch | 10/02/2008 | |
| **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) | Received as partial consideration for the exchange of 12,916 membership units of United Insurance Holdings, L.C., pursuant to the Agreement and Plan of Merger, dated as of April 2, 2008, as amended and restated on August 15, 2008 and further amended as of September 23, 2008, by and among FMG Acquisition Corp. ("FMG"), United Insurance Holdings, L.C. ("United") and United Subsidiary Corp. (the "Merger Agreement"). The consideration for the exchange of such membership units also consisted of cash and the common stock purchase warrants reported in Table II of this Form 4. The Merger Agreement further provides that the former members of United may receive additional cash if certain earnings goals are met. September 30, 2008, the effective date of the merger, the closing price of FMG's common stock was $4.40 per share. In connection with the merger, FMG changed its name to United Insurance Holdings Corp. |
| (2) | Received as partial consideration for the exchange of 1,328 membership units of United Insurance Holdings, L.C., pursuant to the Agreement and Plan of Merger, dated as of April 2, 2008, as amended and restated on August 15, 2008 and further amended as of September 23, 2008, by and among FMG Acquisition Corp. ("FMG"), United Insurance Holdings, L.C. ("United") and United Subsidiary Corp. (the "Merger Agreement"). The consideration for the exchange of such membership units also consisted of cash and the common stock purchase warrants reported in Table II of this Form 4. The Merger Agreement further provides that the former members of United may receive additional cash if certain earnings goals are met. September 30, 2008, the effective date of the merger, the closing price of FMG's common stock was $4.40 per share. In connection with the merger, FMG changed its name to United Insurance Holdings Corp. |
| (3) | Received as partial consideration for the exchange of 2,810 membership units of United Insurance Holdings, L.C., pursuant to the Agreement and Plan of Merger, dated as of April 2, 2008, as amended and restated on August 15, 2008 and further amended as of September 23, 2008, by and among FMG Acquisition Corp. ("FMG"), United Insurance Holdings, L.C. ("United") and United Subsidiary Corp. (the "Merger Agreement"). The consideration for the exchange of such membership units also consisted of cash and the common stock purchase warrants reported in Table II of this Form 4. The Merger Agreement further provides that the former members of United may receive additional cash if certain earnings goals are met. September 30, 2008, the effective date of the merger, the closing price of FMG's common stock was $4.40 per share. In connection with the merger, FMG changed its name to United Insurance Holdings Corp. |
| (4) | The reporting person is the President of Branch Real Estate Services Inc., which serves as the General Partner for the Greg Branch Family LP and disclaims beneficial ownership of these securities except to the extent of his pecuniary interest therein. The inclusion of these shares in this report shall not be deemed an admission of beneficial ownership of all of the reported shares for purposes of Section 16 or for any other purpose. |
| (5) | The warrants will become exercisable on October 4, 2008 and will expire on the earlier of (i) October 4, 2011 or (ii) the date fixed for redemption under the terms of the warrant agreement. |