0001209191-16-098800.txt : 20160216
0001209191-16-098800.hdr.sgml : 20160215
20160216165902
ACCESSION NUMBER: 0001209191-16-098800
CONFORMED SUBMISSION TYPE: 5
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20151231
FILED AS OF DATE: 20160216
DATE AS OF CHANGE: 20160216
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: 5
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-36804
FILM NUMBER: 161429860
MAIL ADDRESS:
STREET 1: PATRIOT NATIONAL, INC.
STREET 2: 401 EAST LAS OLAS BOULEVARD, SUITE 1650
CITY: FORT LAUDERDALE
STATE: FL
ZIP: 33301
5
1
doc5.xml
FORM 5 SUBMISSION
X0306
5
2015-12-31
0
0
1
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
2015-08-20
4
P
0
L
8914
15.38
A
1316312
I
By Steven M. Mariano Trust
Common Stock
2015-08-26
4
P
0
L
100
16.00
A
1316412
I
By Steven M. Mariano Trust
Common Stock
2015-08-31
4
P
0
L
1942
16.25
A
1318356
I
By Steven M. Mariano Trust
Common Stock
12066175
D
Common Stock
1014607
I
By corporation
The price reported in Column 4 is a weighted average price. These shares were purchased in multiple transactions at prices ranging from $15.29 to $15.40, inclusive. The reporting person undertakes to provide to Patriot National, Inc., any security holder of Patriot National, Inc., or the staff of the Securities and Exchange Commission, upon request, full information regarding the number of shares purchased at each separate price within the range set forth in this footnote.
An audit of Mr. Mariano's trust account revealed the Form 3 filed on January 15, 2015 under-reported his ownership by two (2) shares. These shares have been added to correctly reflect his total indirect ownership through his trust.
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 5 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.
By: /s/ Christopher A. Pesch, by power of attorney
2016-02-16