0001209191-17-032079.txt : 20170512 0001209191-17-032079.hdr.sgml : 20170512 20170512171858 ACCESSION NUMBER: 0001209191-17-032079 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20161130 FILED AS OF DATE: 20170512 DATE AS OF CHANGE: 20170512 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: 17839938 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 2016-11-30 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 2016-11-30 4 J 0 3950000 D 8065238 D Common Stock 2017-05-10 4 J 0 900000 D 7165238 D Common Stock 6830088 I By Corporation Common Stock 626428 I By Steven M. Mariano Trust On November 30, 2016, the Reporting Person transferred 3,950,000 shares of common stock that were previously held directly to a corporation controlled by the Reporting Person. The 3,950,000 shares were previously incorrectly reported on the Form 4 filed on January 10, 2017 as being held directly by the Reporting Person. On May 10, 2017, the Reporting Person transferred 900,000 shares of common stock that were previously held directly to a corporation controlled by the Reporting Person for value. Includes the 3,950,000 shares and 900,000 shares transferred from direct ownership to indirect ownership, as reported herein. /s/ Beth Crews, by power of attorney 2017-05-12