SEC FORM
4
SEC Form 4
FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
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OMB APPROVAL |
OMB Number: |
3235-0287 |
Estimated average burden |
hours per response: |
0.5 |
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b). |
1. Name and Address of Reporting Person*
10375 PROFESSIONAL CIRCLE |
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(Street)
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2. Issuer Name and Ticker or Trading Symbol
Employers Holdings, Inc.
[ EIG ]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X |
Director |
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10% Owner |
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Officer (give title below) |
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Other (specify below) |
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3. Date of Earliest Transaction
(Month/Day/Year) 05/13/2009
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4. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
X |
Form filed by One Reporting Person |
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Form filed by More than One Reporting Person |
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned |
1. Title of Security (Instr.
3)
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2. Transaction Date
(Month/Day/Year) |
2A. Deemed Execution Date, if any
(Month/Day/Year) |
3. Transaction Code (Instr.
8)
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4. Securities Acquired (A) or Disposed Of (D) (Instr.
3, 4 and 5)
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5.
Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr.
3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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7. Nature of Indirect Beneficial Ownership (Instr.
4)
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Code |
V |
Amount |
(A) or (D) |
Price |
Common Stock, par value $0.01 |
05/13/2009 |
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P |
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1,000 |
A |
$10
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9,593 |
D |
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Common Stock, par value $0.01 |
05/13/2009 |
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P |
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200 |
A |
$9.92
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9,793 |
D |
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Common Stock, par value $0.01 |
05/13/2009 |
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P |
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300 |
A |
$9.94
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10,093 |
D |
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Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities)
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1. Title of Derivative Security (Instr.
3)
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2. Conversion or Exercise Price of Derivative Security
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3. Transaction Date
(Month/Day/Year) |
3A. Deemed Execution Date, if any
(Month/Day/Year) |
4. Transaction Code (Instr.
8)
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5.
Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr.
3, 4 and 5)
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6. Date Exercisable and Expiration Date
(Month/Day/Year) |
7. Title and Amount of Securities Underlying Derivative Security (Instr.
3 and 4)
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8. Price of Derivative Security (Instr.
5)
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9.
Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr.
4)
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10. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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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 |
Explanation of Responses: |
Remarks: |
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/s/ Lenard T. Ormsby, attorney in fact |
05/15/2009 |
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** Signature of Reporting Person |
Date |
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. |
* 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). |
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure. |
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 Number. |
POWER OF ATTORNEY
I, Michael D. Rumbolz, hereby constitute and appoint Lenard T. Ormsby as my true
and lawful attorney-in-fact and agent, with full power of substitution and
resubstitution for me and in my name, place and stead, in any and all
capacities, to sign any or all required filings or amendments to such filings
with the Securities and Exchange Commission (the "SEC") with respect to my
reporting obligations under Section 16 of the Securities Exchange Act of 1934,
as amended, for EIG Mutual Holding Company (to be renamed Employers Holdings,
Inc.) and to file the same with the SEC, granting unto said attorney-in-fact and
agents, and each of them, full power and authority to do and perform each and
every act and thing necessary or appropriate to be done with respect to such
filings in the premises, as fully to all intents and purposes as he might or
could do in person, hereby ratifying and confirming all that said
attorney-in-fact and agents, or any of them, or their or his substitute or
substitutes, may lawfully do or cause to be done by virtue thereof. This power
of attorney shall continue in effect until specifically terminated in writing by
me.
/s/ Michael D. Rumbolz
Name: Michael D. Rumbolz
STATE OF NEVADA
COUNTY OF CLARK
The foregoing instrument was acknowledged before me this 26th day of January,
2007 by Michael D. Rumbolz, who is personally known to me or who has produced US
passport as identification.
/s/ Bonnie S. Pond
Signature of person taking acknowledgment
Bonnie S. Pond
Name typed, printed, or stamped
Notary Public
Title or rank
94-2025-1
Serial number (if applicable)