0001140361-20-001371.txt : 20200123 0001140361-20-001371.hdr.sgml : 20200123 20200123201010 ACCESSION NUMBER: 0001140361-20-001371 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20200122 FILED AS OF DATE: 20200123 DATE AS OF CHANGE: 20200123 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: 20543483 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 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: 20543484 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: Kosloske Michael W CENTRAL INDEX KEY: 0001569146 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-35811 FILM NUMBER: 20543485 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 2020-01-22 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 2020-01-22 4 J 0 900000 0 A 900000 I See Footnote Class B Common Stock 2020-01-22 4 J 0 900000 0 D 1016667 I See Footnote Class A Common Stock 5643 I See Footnote Reflects the exchange of shares of Class B Common Stock, together with an equal number of Series B Membership Interests of HPIH, into shares of Class A Common Stock pursuant to the Exchange Agreement, dated February 13, 2013, between the reporting persons and issuer. This number of shares consists of shares of Class A Common Stock held of record by HPI and HPIS. HPIS owns 9,000 of such shares and the remainder are held by HPI. 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. 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 1,005,701 shares of Class B Common Stock held of record by HPI and 10,966 shares of Class B 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 B Common Stock held of record by each of HPI and HPIS. By Lori Kosloske. Michael Kosloske and Lori Kosloske are husband and wife. /s/ Michael W. Kosloske 2020-01-22