0001209191-22-058860.txt : 20221128 0001209191-22-058860.hdr.sgml : 20221128 20221128162434 ACCESSION NUMBER: 0001209191-22-058860 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20221123 FILED AS OF DATE: 20221128 DATE AS OF CHANGE: 20221128 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: PETCOFF JAMES G CENTRAL INDEX KEY: 0001115666 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-37536 FILM NUMBER: 221425764 MAIL ADDRESS: STREET 1: 350 N NINTH STREET STREET 2: SUITE 202 CITY: BOISE STATE: ID ZIP: 83702 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Conifer Holdings, Inc. CENTRAL INDEX KEY: 0001502292 STANDARD INDUSTRIAL CLASSIFICATION: FIRE, MARINE & CASUALTY INSURANCE [6331] IRS NUMBER: 271298795 STATE OF INCORPORATION: MI FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 3001 WEST BIG BEAVER ROAD STREET 2: SUITE 200 CITY: TROY STATE: MI ZIP: 48084 BUSINESS PHONE: (248) 559-0840 MAIL ADDRESS: STREET 1: 3001 WEST BIG BEAVER ROAD STREET 2: SUITE 200 CITY: TROY STATE: MI ZIP: 48084 4 1 doc4.xml FORM 4 SUBMISSION X0306 4 2022-11-23 0 0001502292 Conifer Holdings, Inc. CNFR 0001115666 PETCOFF JAMES G 3001 WEST BIG BEAVER ROAD SUITE 200 TROY MI 48084 1 1 1 0 Executive Chairman and Co-CEO Common Stock 2022-11-23 4 P 0 30000 1.58 A 54543 I PH Real Estate, LLC Common Stock 2898607 I James G. Petcoff Rev Trust Common Stock 480275 D These shares are owned by PH Real Estate, LLC, a Michigan limited liability company. Mr. James G. Petcoff and his spouse have a majority interest in PH Real Estate, LLC and have the sole power to vote and dispose of all shares owned by PH Real Estate, LLC. These shares are owned indirectly by Mr. Petcoff as trustee of the James G. Petcoff Revocable Trust. Mr. Petcoff is Chairman, Co-CEO and a director of the issuer. Brian J. Roney, by Power of Attorney 2022-11-28