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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549ANNUAL STATEMENT 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 2270 (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 at End of Issuer's Fiscal Year (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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(A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Lone Tree Holdings Ltd C/O WHITE MOUNTAINS INSURANCE GROUP LTD. 80 SOUTH MAIN ST. HANOVER, NH 03755 |
 |  X |  |  |
Jason R. Lichtenstein by Power of Attorney | 02/02/2012 | |
**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) | The Reporting Person is an indirect wholly-owned subsidiary of White Mountains Insurance Group, Ltd. ("WMIG"), a public company which also reports beneficial ownership of all the Class B Common Shares ("Class B Shares") referenced in this filing. The Reporting Person became the direct beneficial owner of 72,400,000 Class B Shares via a contribution from its direct parent on December 14, 2006 (the contributor was also an indirect wholly-owned subsidiary of WMIG). On March 15, 2007, 645,262 Class B Shares were sold by the Reporting Person to the Issuer's ESOP (as disclosed in this filing and in a Form 4 filed by WMIG on such date). The remaining 71,754,738 Class B Shares have been held directly by the Reporting Person, or by one or more of its wholly-owned subsidiaries, since that time. |
(2) | Reflects reduction in Class B Shares reported as held directly as a result of transfers from the Reporting Person to its indirect wholly-owned subsidiary, Sirius International Holdings (NL) B.V. ("SIH") on August 15, 2008 and July 1, 2011. Class B Shares were transferred from SIH to Star Re Ltd. ("Star Re") on December 6, 2011. |
(3) | Reflects Class B Shares transferred to SIH from the Reporting Person on August 15, 2008 and July 1, 2011, less 1,249,178 Class B Shares transferred by SIH to Star Re on December 6, 2011. |
(4) | Reflects Class B Shares transferred from SIH to Star Re on December 6, 2011. |