Initial Statement of Beneficial Ownership (3)
12 Março 2013 - 12:18PM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0104
Estimated average burden
hours per response...
0.5
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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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1. Name and Address of Reporting Person
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Health Plan Intermediaires, LLC
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2. Date of Event Requiring Statement (MM/DD/YYYY)
2/7/2013
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3. Issuer Name
and
Ticker or Trading Symbol
Health Insurance Innovations, Inc. [HHIQ]
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(Last)
(First)
(Middle)
15438 N. FLORIDA AVENUE, SUITE 201
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director
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X
___ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Street)
TAMPA, FL 33613
(City)
(State)
(Zip)
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5. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_
X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Beneficially Owned
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1.Title of Security
(Instr. 4)
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2. Amount of Securities Beneficially Owned
(Instr. 4)
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3. Ownership Form: Direct (D) or Indirect (I)
(Instr. 5)
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4. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Table II - Derivative Securities Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 4)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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3. Title and Amount of Securities Underlying Derivative Security
(Instr. 4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 5)
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6. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Class B Common Stock
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(1)
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(1)
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Class A Common Stock
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8580000
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(1)
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I
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See footnote
(1)
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Explanation of Responses:
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(
1)
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This number of shares consists of 8,580,000 shares of Class B common stock held of record by Health Plan Intermediaries, LLC ("HPI"). Michael W. Kosloske is the sole member and primary manager of HPI, and has sole voting and dispositive power over the shares held by HPI. Michael W. Kosloske, by virtue of his control of HPI, may be deemed to beneficially own all the shares of Class B common stock held of record by HPI. The shares of Class B common stock, together with the Series B Membership Interests of HPI, are exchangeable, at Michael W. Kosloske's election, for equal number of shares of Class A common stock. This exchange right has no expiration date.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Health Plan Intermediaires, LLC
15438 N. FLORIDA AVENUE, SUITE 201
TAMPA, FL 33613
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X
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Signatures
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/s/ Joan Rodgers, as Attorney-in-Fact
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3/12/2013
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 5(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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.
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