0001209191-23-021204.txt : 20230327
0001209191-23-021204.hdr.sgml : 20230327
20230327160533
ACCESSION NUMBER: 0001209191-23-021204
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20230324
FILED AS OF DATE: 20230327
DATE AS OF CHANGE: 20230327
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: 23764560
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
X0407
4
2023-03-24
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
0
Common Stock
2023-03-24
4
P
0
200000
1.51
A
680275
D
Common Stock
2698607
I
James G. Petcoff Rev Trust
Common Stock
58765
I
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.
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.
Brian J. Roney, by Power of Attorney
2023-03-27