0001209191-17-029795.txt : 20170503
0001209191-17-029795.hdr.sgml : 20170503
20170503183904
ACCESSION NUMBER: 0001209191-17-029795
CONFORMED SUBMISSION TYPE: 3
PUBLIC DOCUMENT COUNT: 2
CONFORMED PERIOD OF REPORT: 20170423
FILED AS OF DATE: 20170503
DATE AS OF CHANGE: 20170503
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: Patriot National, Inc.
CENTRAL INDEX KEY: 0001619917
STANDARD INDUSTRIAL CLASSIFICATION: INSURANCE AGENTS BROKERS & SERVICES [6411]
IRS NUMBER: 464151376
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 401 E. LAS OLAS BLVD.
STREET 2: SUITE 1650
CITY: FORT LAUDERDALE
STATE: FL
ZIP: 33301
BUSINESS PHONE: (954) 670-2900
MAIL ADDRESS:
STREET 1: 401 E. LAS OLAS BLVD.
STREET 2: SUITE 1650
CITY: FORT LAUDERDALE
STATE: FL
ZIP: 33301
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: COLEMAN TERRY L
CENTRAL INDEX KEY: 0001184500
STATE OF INCORPORATION: GA
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 3
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-36804
FILM NUMBER: 17811080
3
1
doc3.xml
FORM 3 SUBMISSION
X0206
3
2017-04-23
1
0001619917
Patriot National, Inc.
PN
0001184500
COLEMAN TERRY L
C/O PATRIOT NATIONAL
401 EAST LAS OLAS BLVD, SUITE 1650
FORT LAUDERDALE
FL
33301
1
0
0
0
Exhibit 24 - Power of Attorney
No securities are beneficially owned.
By: /s/ Beth Crews, by power of attorney
2017-05-03
EX-24.3_721133
2
poa.txt
POA DOCUMENT
POWER OF ATTORNEY
Know all by these presents that Terry L. Coleman, does hereby make,
constitute and appoint each of Gex F. Richardson and Beth A. Crews, or any one
of them, as a true and lawful attorney-in-fact of the undersigned with full
powers of substitution and revocation, for and in the name, place and stead of
the undersigned (in the undersigned's individual capacity), to execute and
deliver such forms that the undersigned may be required to file with the U.S.
Securities and Exchange Commission as a result of the undersigned's ownership of
or transactions in securities of Patriot National, Inc. (i) pursuant to Section
16(a) of the Securities Exchange Act of 1934, as amended, including without
limitation, statements on Form 3, Form 4 and Form 5 (including any amendments
thereto) and (ii) in connection with any applications for EDGAR access codes,
including without limitation the Form ID.
The Power of Attorney shall remain in full force and effect until the
undersigned is no longer required to file Forms 3, 4 and 5 with regard to his
ownership of or transactions in securities of Patriot National, Inc., unless
earlier revoked in writing. The undersigned acknowledges that Gex F. Richardson
and Beth A. Crews are not assuming any of the undersigned's responsibilities to
comply with Section 16 of the Securities Exchange Act of 1934.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney
to be executed as of this 2 day of May, 2017.
Sign: /s/ Terry L. Coleman
Name: Terry L. Coleman