0001140361-19-010576.txt : 20190606
0001140361-19-010576.hdr.sgml : 20190606
20190606150817
ACCESSION NUMBER: 0001140361-19-010576
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20190604
FILED AS OF DATE: 20190606
DATE AS OF CHANGE: 20190606
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: 19882313
MAIL ADDRESS:
STREET 1: C/O HEALTH INSURANCE INNOVATIONS, INC.
STREET 2: 15438 N. FLORIDA AVENUE, SUITE 201
CITY: TAMPA
STATE: FL
ZIP: 33613
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Health Plan Intermediaires, LLC
CENTRAL INDEX KEY: 0001571686
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-35811
FILM NUMBER: 19882314
BUSINESS ADDRESS:
STREET 1: C/O HEALTH INSURANCE INNOVATIONS, INC.
STREET 2: 15438 N. FLORIDA AVENUE, SUITE 201
CITY: TAMPA
STATE: FL
ZIP: 33613
BUSINESS PHONE: (877) 376-5831
MAIL ADDRESS:
STREET 1: C/O HEALTH INSURANCE INNOVATIONS, INC.
STREET 2: 15438 N. FLORIDA AVENUE, SUITE 201
CITY: TAMPA
STATE: FL
ZIP: 33613
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Health Plan Intermediaries Sub, LLC
CENTRAL INDEX KEY: 0001571685
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-35811
FILM NUMBER: 19882315
BUSINESS ADDRESS:
STREET 1: C/O HEALTH INSURANCE INNOVATIONS, INC.
STREET 2: 15438 N. FLORIDA AVENUE, SUITE 201
CITY: TAMPA
STATE: FL
ZIP: 33613
BUSINESS PHONE: (877) 376-5831
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
form4.xml
FORM 4
X0306
4
2019-06-04
0001561387
Health Insurance Innovations, Inc.
HIIQ
0001569146
Kosloske Michael W
16221 VILLARREAL DE AVILA
TAMPA
FL
33613
true
0001571686
Health Plan Intermediaires, LLC
C/O HEALTH INSURANCE INNOVATIONS, INC.
15438 N. FLORIDA AVENUE, SUITE 201
TAMPA
FL
33613
true
0001571685
Health Plan Intermediaries Sub, LLC
C/O HEALTH INSURANCE INNOVATIONS, INC.
15438 N. FLORIDA AVENUE, SUITE 201
TAMPA
FL
33613
true
Class A Common Stock
2019-06-04
4
M
0
40834
23.8
A
105136
D
Class A Common Stock
2019-06-04
4
D
0
33816
28.74
D
71320
D
Class B Common Stock
2416667
I
See Footnote
Class A Common Stock
125000
I
See Footnote
Class A Common Stock
5643
I
See Footnote
Stock Appreciation Rights
23.8
2019-06-04
4
M
0
40834
0
D
2019-06-07
Class A Common Stock
40834
0
D
Membership Interests in Health Plan Intermediaries Holdings,
0
Class A Common Stock
0
2416667
I
See Footnote
Represents the exercise of stock appreciation rights prior to the expiration thereof.
Shares retained by the issuer to satisfy the exercise price of stock appreciation rights exercised by the Reporting Person.
Each share of Class B Common Stock held by the reporting persons, together with one Series B Membership Interest held by the reporting persons in Health Plan Intermediaries Holdings, LLC ("HPIH"), are together exchangeable, at any time, at the reporting persons' election, for one share of Class A Common Stock. This exchange right has no expiration date.
This number of shares consists of 2,391,701 shares of Class B Common Stock held of record by Health Plan Intermediaries, LLC ("HPI") and 24,966 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.
This number of shares consists of 123,750 shares of Class A Common Stock held of record by HPI and 1,250 shares of Class A Common Stock held by 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 A Common Stock held of record by each of HPI and HPIS.
By Lori Kosloske. Michael Kosloske and Lori Kosloske are husband and wife.
These stock-settled stock appreciation rights were granted to the Reporting Person under the Issuer's Long-Term Incentive Plan and, in accordance with the terms of the Long-Term Incentive Plan and an award agreement under the Long-Term Incentive Plan, vested in January 2018 upon the termination of the Reporting Person's employment with the Company.
This number consists of 2,391,701 Class B Membership Interests in HPIH held of record by HPI and 24,966 interests held by HPIS. Michael Kosloske is the sole member and primary manager of HPI, and has sole voting and dispositive power over the interests held by HPI. HPI is the sole managing member of HPIS and has sole voting and dispositive power over the interests 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 Class B Membership Interests of HPIH held of record by each of HPI and HPIS.
/s/ Michael W. Kosloske
2019-06-06