Amended Statement of Beneficial Ownership (3/a)
01 Dezembro 2021 - 4:31PM
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
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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
*
Rock Island Investors, LLC |
2. Date of Event Requiring Statement (MM/DD/YYYY)
3/24/2017
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3. Issuer Name and Ticker or Trading Symbol
ICC Holdings, Inc. [ICCH]
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(Last)
(First)
(Middle)
1230 PEACHTREE STREET NE; SUITE 3600 |
4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
_____ Director ___X___ 10% Owner
_____ Officer (give title below) _____ Other (specify below)
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(Street)
ATLANTA, GA 30309
(City)
(State)
(Zip)
| 5. If Amendment, Date Original Filed(MM/DD/YYYY)
3/28/2017
| 6. Individual or Joint/Group Filing(Check Applicable Line)
___ Form filed by One Reporting Person
_X_ 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) | 2. Amount of Securities Beneficially Owned
(Instr. 4) | 3. Ownership Form: Direct (D) or Indirect (I)
(Instr. 5) | 4. Nature of Indirect Beneficial Ownership
(Instr. 5) |
| Common Stock | 400000 (1) | D | |
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) | 2. Date Exercisable and Expiration Date
(MM/DD/YYYY) | 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) |
| Date Exercisable | Expiration Date | Title | Amount or Number of Shares |
| Explanation of Responses: |
| (1) | These securities are owned directly by Rock Island Investors, LLC. This Form 3/A is being filed to amend the original Form 3 filed by Rock Island Investors, LLC and Patrick R. Leardo to reflect Rock Island Investors, LLC's pecuniary interest in all securities it owns directly. Mr. Leardo is exempt by virtue of Rule 16a-1(a)(1)(vii) of the Securities Exchange Act of 1934. |
Reporting Owners
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| Reporting Owner Name / Address | Relationships |
| Director | 10% Owner | Officer | Other |
Rock Island Investors, LLC
1230 PEACHTREE STREET NE; SUITE 3600
ATLANTA, GA 30309 |
| X |
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Leardo Patrick R.
1230 PEACHTREE STREET NE; SUITE 3600
ATLANTA, GA 30309 |
| X |
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Signatures
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| Rock Island Investors, LLC, By: /s/ John Luckett, Jr., its Authorized Representative | | 12/1/2021 |
| **Signature of Reporting Person | Date |
| /s/ Patrick R. Leardo | | 12/1/2021 |
| **Signature of Reporting Person | Date |
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