0001209191-15-086122.txt : 20151218
0001209191-15-086122.hdr.sgml : 20151218
20151218164322
ACCESSION NUMBER: 0001209191-15-086122
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20151216
FILED AS OF DATE: 20151218
DATE AS OF CHANGE: 20151218
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: Mariano Steven M.
CENTRAL INDEX KEY: 0001480753
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-36804
FILM NUMBER: 151297285
MAIL ADDRESS:
STREET 1: PATRIOT NATIONAL, INC.
STREET 2: 401 EAST LAS OLAS BOULEVARD, SUITE 1650
CITY: FORT LAUDERDALE
STATE: FL
ZIP: 33301
4
1
doc4.xml
FORM 4 SUBMISSION
X0306
4
2015-12-16
0
0001619917
Patriot National, Inc.
PN
0001480753
Mariano Steven M.
C/O PATRIOT NATIONAL, INC.
401 E. LAS OLAS BLVD., SUITE 1650
FORT LAUDERDALE
FL
33301
1
1
1
0
See Remarks
Common Stock
2015-12-16
4
S
0
2500000
D
12066175
D
Common Stock
1307398
I
By Steven M. Mariano Trust
Common Stock
1014607
I
By Corporation
Obligation to Sell
2015-12-16
4
D
0
1250000
D
Common Stock
1250000
1250000
D
Pursuant to the terms of a Securities Purchase Agreement dated as of December 13, 2015 (the "Purchase Agreement"), by and among the Issuer, the Reporting Person and the purchasers named therein (the "Purchasers"), the Reporting Person sold to the Purchasers an aggregate of 2,500,000 shares of issuer common stock ("Common Stock") for an aggregate purchase price of $30 million. Additionally, pursuant to the Purchase Agreement, the Issuer issued and sold to the Purchasers (i) 666,666 shares of Common Stock and prepaid Series B warrants for 1,000,000 shares of Common Stock (the "Series B Warrants"), and (ii) Series A warrants to purchase up to an aggregate of 2,083,333 shares of Common Stock (the "Series A Warrants", and together with the Series B Warrants, the "Warrants"), for an aggregate purchase price of approximately $20 million. The transaction described herein (the "Transaction") closed on December 16, 2015.
On December 13, 2015, the Issuer and the Reporting Person entered into an agreement (the "Stock Back-to-Back Agreement") pursuant to which the Issuer will repurchase a number of shares of Common Stock owned by the Reporting Person equal to 60% of the shares of Common Stock to be issued by the Issuer to the Purchasers in connection with the exercise by Purchasers of the Warrants.
This obligation to sell under the Stock Back-to-Back Agreement relates to the Series A Warrants. The Series A Warrants are exercisable at the lower of $15 per share or a variable exercise price described therein. The Series A Warrants are exercisable beginning on July 1, 2016 and expire on June 30, 2018.
President and Chief Executive Officer
The Reporting Person disclaims beneficial ownership of the securities reported herein as indirectly beneficially owned, except to the extent of his pecuniary interest therein. The filing of this Form 4 shall not be deemed to be an admission that the Reporting Person is the beneficial owner of any of the securities reported herein for purposes of Section 16 of the Securities Exchange Act of 1934, as amended, or otherwise.
/s/ Christopher A. Pesch, by power of attorney
2015-12-18