0001140361-17-043406.txt : 20171120
0001140361-17-043406.hdr.sgml : 20171120
20171120173506
ACCESSION NUMBER: 0001140361-17-043406
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20171116
FILED AS OF DATE: 20171120
DATE AS OF CHANGE: 20171120
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Kosloske Michael W
CENTRAL INDEX KEY: 0001569146
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-35811
FILM NUMBER: 171214875
MAIL ADDRESS:
STREET 1: C/O HEALTH INSURANCE INNOVATIONS, INC.
STREET 2: 15438 N. FLORIDA AVENUE, SUITE 201
CITY: TAMPA
STATE: FL
ZIP: 33613
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: Health Insurance Innovations, Inc.
CENTRAL INDEX KEY: 0001561387
STANDARD INDUSTRIAL CLASSIFICATION: INSURANCE AGENTS BROKERS & SERVICES [6411]
IRS NUMBER: 461282634
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 15438 N. FLORIDA AVENUE
STREET 2: SUITE 201
CITY: TAMPA
STATE: FL
ZIP: 33613
BUSINESS PHONE: 813-397-1187
MAIL ADDRESS:
STREET 1: 15438 N. FLORIDA AVENUE
STREET 2: SUITE 201
CITY: TAMPA
STATE: FL
ZIP: 33613
4
1
doc1.xml
FORM 4
X0306
4
2017-11-16
0
0001561387
Health Insurance Innovations, Inc.
HIIQ
0001569146
Kosloske Michael W
15438 N. FLORIDA AVENUE
SUITE 201
TAMPA
FL
33613
1
1
1
0
Chief of Product Innovation
Class A Common Stock
100
D
Class A Common Stock
7203
I
See Footnote
Class A Common Stock
26079
I
See Footnote
Class A Common Stock
3841667
I
See Footnote
Stock Appreciation Rights
23.80
2017-11-16
4
A
0
40834
0
A
2024-11-16
Common Stock
40834
40834
D
Stock Appreciation Rights
9.8
2023-11-19
Common Stock
106173
106173
D
By Lori Kosloske. Michael Kosloske and Lori Kosloske are husband and wife.
By Michael W. Kosloske 2012 Descendants Trust Agreement dated December 7, 2012, Lori Kosloske as Directing Trustee.
This number of shares consists of 3,802,451 shares of Class B Common Stock held of record by Health Plan Intermediaries, LLC ("HPI") and 39,216 shares of Class B Common Stock held by Health Plan Intermediaries Sub, LLC ("HPIS"). Michael Kosloske is the sole member and primary manager of HPI, and has sole voting and dispositive power over the shares held by HPI. HPI is the sole managing member of HPIS and has sole voting and dispositive power over the shares held by HPIS. Mr. Kosloske, by virtue of his control of HPI and HPI's control of HPIS, may be deemed to beneficially own all the shares of Class B Common Stock held of record by each of HPI and HPIS. The shares of Class B Common Stock, together with the Series B Membership Interests of HPI, are exchangeable, at Mr. Kosloske's election, for equal numbers of shares of Class A Common Stock. This exchange right has no expiration date.
These stock-settled stock appreciation rights were granted to the Reporting Person under the Issuer's Long-Term Incentive Plan and vest 25% on each of the first and second anniversaries of grant date and 50% on the third anniversary, subject to the terms of the Long-Term Incentive Plan and an award agreement under the Long-Term Incentive Plan.
These stock-settled stock appreciation rights were granted to the Reporting Person under the Issuer's Long-Term Incentive Plan and vest 25% on each of the first and second anniversaries of grant date and 50% on the third anniversary, subject to the terms of the Long-Term Incentive Plan and an award agreement under the Long-Term Incentive Plan.
/s/ Michael Hershberger, as Attorney-in-Fact
2017-11-20