5 1 kingsway_form5.txt FORM 5 U.S. SECURITIES AND EXCHANGE COMMISSION Washington, DC 20549 FORM 5 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP 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(f) of the Investment Company Act of 1940 [_] Check box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). [x] Form 3 Holdings Reported [_] Form 4 Transactions Reported ________________________________________________________________________________ 1. Name and Address of Reporting Person* Kingsway Financial Services Inc. -------------------------------------------------------------------------------- (Last) (First) (Middle) 5310 Explorer Drive -------------------------------------------------------------------------------- (Street) Mississauga, Ontario L4W 5H8 Canada -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Issuer Name and Ticker or Trading Symbol American Country Holdings, Inc. (ACHI) ________________________________________________________________________________ 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) ________________________________________________________________________________ 4. Statement for Month/Year December 31, 2001 ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Year) ________________________________________________________________________________ 6. Relationship of Reporting Person to Issuer (Check all applicable) [_] Director [x] 10% Owner [_] Officer (give title below) [_] Other (specify below) ________________________________________________________________________________ 7. Individual or Joint/Group Filing (Check applicable line) [_] Form filed by one Reporting Person [x] Form filed by more than one Reporting Person ________________________________________________________________________________ ================================================================================ Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned ================================================================================

* If the form is filed by more than one Reporting Person, see Instruction 4(b)(v). Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Print or Type Responses) (Over) FORM 5 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================

/s/ William G. Star February 20, 2002 --------------------------------------------- ----------------------- **Signature of Reporting Person Date WILLIAM STAR PRESIDENT ** 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 provided is insufficient, see Instruction 6 for procedure. JOINT FILER INFORMATION Name: American Service Insurance Company, Inc. Address: c/o Kingsway Financial Services, Inc. 5310 Explorer Drive Mississauga, Ontario L4W5H8 Canada Designated Filer: Kingsway Financial Services Inc. Date of Event Requiring Statement: July 2, 2001 Signature: /s/ James R. Zuhlke ----------------------------- Name: James R. Zuhlke Title: Chairman JOINT FILER INFORMATION Name: Lincoln General Insurance Company Address: c/o Kingsway Financial Services, Inc. 5310 Explorer Drive Mississauga, Ontario L4W5H8 Canada Designated Filer: Kingsway Financial Services Inc. Date of Event Requiring Statement: July 2, 2001 Signature: /s/ William G. Star ----------------------------- Name: William G. Star Title: President and Chief Executive Officer JOINT FILER INFORMATION Name: Universal Casualty Company Address: c/o Kinsway Financial Services, Inc. 5310 Explorer Drive Mississauga, Ontario L4W5H8 Canada Designated Filer: Kingsway Financial Services Inc. Date of Event Requiring Statement: July 2, 2001 Signature: /s/ Marc Romanz ----------------------------- Name: Marc Romanz Title: Chief Operating Officer

AMERICAN COUNTRY HOLDINGS INC 5