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