Form of Common Stock Certificate




 Exhibit 4.1 
  
 

 
  
 NUMBER AFFM SHARES

 AFFIRMATIVE INSURANCE HOLDINGS, INC. 
 COMMON STOCK 
 SEE REVERSE FOR CERTAIN DEFINITIONS 
 CUSIP 008272 10 6 
 INCORPORATED UNDER THE LAWS OF THE STATE OF DELAWARE 
 THIS CERTIFICATE IS TRANSFERABLE IN CANTON, MA, JERSEY
CITY, NJ OR NEW YORK, NY 
 THIS CERTIFIES THAT is the owner of fully paid and non-assessable shares of COMMON STOCK of the
par value of $.01 per share, of 
 AFFIRMATIVE INSURANCE HOLDINGS, INC. 
 transferable on the books of the Corporation by the holder hereof in person or by duly authorized attorney upon surrender of this
certificate properly endorsed. This certificate is not valid until countersigned by the Transfer Agent and registered by the Registrar. IN WITNESS WHEREOF, the Corporation has caused the facsimile signatures of its duly authorized officers and its
facsimile seal to be hereunto affixed. 
 COUNTERSIGNED AND REGISTERED: 
 EQUISERVE TRUST COMPANY, N.A. 
 BY TRANSFER AGENT AND REGISTRAR 
 AUTHORIZED SIGNATURE 
 SECRETARY 
 PRESIDENT AND CHIEF EXECUTIVE OFFICER 








 AFFIRMATIVE INSURANCE HOLDINGS, INC. 
  
 The Corporation will furnish without charge to each
stockholder who so requests the powers, designations, preferences and relative, participating, optional or other special rights of each class of stock or series thereof and the qualifications, limitations or restrictions of such preferences and/or
rights. Such requests shall be made to the Corporation’s Secretary at the principal office of the Corporation. 
  
 The following abbreviations, when used in the inscription on the face of this certificate, shall be construed as though they were written
out in full according to applicable laws or regulations: 
  

															
	 TEN COM
	 	—	 	as tenants in common	  	UNIF TRANS MIN ACT	 	—	 	............................	 	Custodian	 	....................
	 TEN ENT
	 	—	 	as tenants by the entireties	  	 	 	 	 	(Cust)	 	 	 	(Minor)
	 JT TEN
	 	—	 	as joint tenants with right of	  	 	 	 	 	under Uniform Transfer to Minors
	 	 	 	 	survivorship and not as tenants	  	 	 	 	 	Act ...............................................................
	 	 	 	 	in common	  	 	 	 	 	 	 	(Minor)	 	 

  
 Additional abbreviations may also be used though not in the above list. 
  
         For value received,
                                        
                                        
                                    hereby sell, assign and transfer
unto 
  

			
	PLEASE INSERT SOCIAL SECURITY OR OTHER	  	 
	IDENTIFICATION NUMBER OF ASSIGNEE	  	 
	 	  	 

  
  

 (PLEASE PRINT OR TYPEWRITE NAME AND ADDRESS INCLUDING ZIP CODE OF ASSIGNEE) 
  
  

  
  

  
  

			
	
	 	shares

 of the common stock represented by the within certificate and do hereby irrevocably constitute and
appoint 
  
  

			
	
	 	Attorney

 to transfer the said stock on the books of the within-named corporation with full power of
substitution in the premises. 
  

			
		
	Dated	 	 
	 	 	 

  

					
	 	 	

	 	 	NOTICE:	 	THE SIGNATURE TO THIS ASSIGNMENT MUST CORRESPOND WITH THE NAME AS WRITTEN UPON THE FACT OF THE CERTIFICATE IN EVERY PARTICULAR WITHOUT ALTERATION OR ENLARGEMENT OR ANY CHANGE
WHATEVER.

  
  

					
	 	  	SIGNATURE GUARANTEED:	 	

	 	  	 	 	THE SIGNATURE(S) SHOULD BE GUARANTEED BY AN ELIGIBLE GUARANTOR INSTITUTION (BANKS, STOCKBROKERS, SAVINGS AND LOAN ASSOCIATIONS AND CREDIT UNIONS WITH MEMBERSHIP IN AN APPROVED
SIGNATURE GUARANTEE MEDALLION PROGRAM, PURSUANT TO S.E.C. RULE 17AD-15.