UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549INITIAL STATEMENT OF 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. | SEC 1473 (7-02) | ||
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. |
1. Title of Derivative Security (Instr. 4) |
2. Date Exercisable and Expiration Date (Month/Day/Year) |
3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) |
4. Conversion or Exercise Price of Derivative Security | 5. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 5) |
6. Nature of Indirect Beneficial Ownership (Instr. 5) |
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Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Kolesar Robert J 9790 GATEWAY DRIVE RENO, NV 89521 |
 X |  |  |  |
/s/ Lenard T. Ormsby, as attorney-in-fact for Robert J. Kolesar | 01/30/2007 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 5(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) | As of the date of this Form 3, Mr. Kolesar has no direct or indirect beneficial interests in any securities of Employers Holdings, Inc. (the "Company"). Mr. Kolesar is the managing partner of Kolesar & Leatham, Chtd., a Las Vegas law firm, which holds a policy issued by Employers Insurance Company of Nevada, a wholly-owned subsidiary of the Company. The policy owned by Kolesar & Leatham, Chtd. entitles it to receive consideration consisting of an estimated 1,041 shares of common stock (assuming no exercise of the over-allotment option granted by the Company to the underwriters) as a result of the conversion of the Company from a Nevada mutual insurance company owned by its policyholders to a Nevada stock corporation. If the over-allotment option is exercised, Kolesar & Leatham, Chtd.'s, entitlement to consideration in the conversion will change. |
(2) | By virtue of his ownership interests in Kolesar & Leatham, Chtd., Mr. Kolesar may be deemed to beneficially own any shares listed as beneficially owned by Kolesar & Leatham, Chtd. Mr. Kolesear will disclaim beneficial ownership of such shares except to the extent of his pecuniary interests therein and the inclusion of the 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 any other purpose. |