0001104659-18-031864.txt : 20180509 0001104659-18-031864.hdr.sgml : 20180509 20180509211927 ACCESSION NUMBER: 0001104659-18-031864 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20180507 FILED AS OF DATE: 20180509 DATE AS OF CHANGE: 20180509 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Hove Anders D CENTRAL INDEX KEY: 0001365618 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38468 FILM NUMBER: 18820223 MAIL ADDRESS: STREET 1: 30 ROCKEFELLER PLAZA, SUITE 5508 CITY: NEW YORK STATE: NY ZIP: 10112 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Kazma Michael D CENTRAL INDEX KEY: 0001702237 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38468 FILM NUMBER: 18820224 MAIL ADDRESS: STREET 1: 980 N FEDERAL HIGHWAY STREET 2: SUITE 315 CITY: BOCA RATON STATE: FL ZIP: 33432 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Amzak Health Investors, LLC CENTRAL INDEX KEY: 0001719184 STATE OF INCORPORATION: FL FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38468 FILM NUMBER: 18820225 BUSINESS ADDRESS: STREET 1: 980 NORTH FEDERAL HIGHWAY, SUITE 315 CITY: BOCA RATON STATE: FL ZIP: 33432 BUSINESS PHONE: 561-953-4164 MAIL ADDRESS: STREET 1: 980 NORTH FEDERAL HIGHWAY, SUITE 315 CITY: BOCA RATON STATE: FL ZIP: 33432 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Inspire Medical Systems, Inc. CENTRAL INDEX KEY: 0001609550 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 261377674 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 9700 63RD AVENUE N STREET 2: SUITE 200 CITY: MAPLE GROVE STATE: X1 ZIP: 55369 BUSINESS PHONE: 763-205-7970 MAIL ADDRESS: STREET 1: 9700 63RD AVENUE N STREET 2: SUITE 200 CITY: MAPLE GROVE STATE: X1 ZIP: 55369 4 1 a4.xml 4 X0306 4 2018-05-07 1 0001609550 Inspire Medical Systems, Inc. INSP 0001719184 Amzak Health Investors, LLC 980 FEDERAL HIGHWAY, SUITE 315 BOCA RATON FL 33432 0 0 1 0 0001702237 Kazma Michael D 980 FEDERAL HIGHWAY, SUITE 315 BOCA RATON FL 33432 0 0 1 0 0001365618 Hove Anders D 980 FEDERAL HIGHWAY, SUITE 315 BOCA RATON FL 33432 0 0 1 0 Common Stock 2018-05-07 4 C 0 1372043 A 1372043 D Common Stock 2018-05-07 4 P 0 125000 16.00 A 1497043 D Series F Convertible Preferred Stock 2018-05-07 4 C 0 9124088 0 D Common Stock 1372043 0 D Shares of Series F Convertible Preferred Stock automatically converted into shares of the Issuer's Common Stock at a 1-for-0.1504 conversion rate immediately prior to the closing of the Issuer's initial public offering for no additional consideration (subject to the payment of cash in lieu of any fractional shares in accordance with the Issuer's Sixth Amended and Restated Certificate of Incorporation, as amended). These shares had no expiration date. These shares are held of record by Amzak Health Investors, LLC ("Amzak Health"). Joyce Erony, a director of the Issuer, Michael D. Kazma, and Anders Hove are managers of Amzak Health and, as a result, have shared voting and dispositive power over the shares held by Amzak Health. Each of Ms. Erony and Mr. Hove disclaims beneficial ownership of the shares held by Amzak Health except to the extent of his or her proportionate pecuniary interest therein. /s/ Richard Buchholz, as Attorney-in-Fact for Amzak Health Investors, LLC 2018-05-09 /s/ Richard Buchholz, as Attorney-in-Fact for Michael D. Kazma 2018-05-09 /s/ Richard Buchholz, as Attorney-in-Fact for Anders Hove 2018-05-09