0001209191-17-052540.txt : 20170913 0001209191-17-052540.hdr.sgml : 20170913 20170913115349 ACCESSION NUMBER: 0001209191-17-052540 CONFORMED SUBMISSION TYPE: 3/A PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20170524 FILED AS OF DATE: 20170913 DATE AS OF CHANGE: 20170913 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Rearer John J CENTRAL INDEX KEY: 0001708041 FILING VALUES: FORM TYPE: 3/A SEC ACT: 1934 Act SEC FILE NUMBER: 001-36804 FILM NUMBER: 171082645 MAIL ADDRESS: STREET 1: C/O PATRIOT NATIONAL, INC. STREET 2: 401 E. LAS OLAS BLVD., SUITE 1650 CITY: FORT LAUDERDALE STATE: FL ZIP: 33301 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 3/A 1 doc3a.xml FORM 3/A SUBMISSION X0206 3/A 2017-05-24 2017-06-05 0 0001619917 Patriot National, Inc. PN 0001708041 Rearer John J C/O 401 E. LAS OLAS BLVD. SUITE 1650 FORT LAUDERDALE FL 33301 0 1 0 0 Chief Executive Officer Employee Stock Options (right to buy) 14.00 2025-01-15 Common Stock 23529 D The options vest in three equal annual installments beginning on January 15, 2016. These options were mistakenly omitted from the Reporting Person's original Form 3 filed June 5, 2017. Exhibit 24 - Power of Attorney By: /s/ Beth A. Crews, by power of attorney 2017-09-13 EX-24.3A_743919 2 poa.txt POA DOCUMENT POWER OF ATTORNEY Know all by these presents that John J. Rearer, does hereby make, constitute and appoint each of Gex F. Richardson and Beth A. Crews, or any one of them, as a true and lawful attorney-in-fact of the undersigned with full powers of substitution and revocation, for and in the name, place and stead of the undersigned (in the undersigned's individual capacity), to execute and deliver such forms that the undersigned may be required to file with the U.S. Securities and Exchange Commission as a result of the undersigned's ownership of or transactions in securities of Patriot National, Inc. (i) pursuant to Section 16(a) of the Securities Exchange Act of 1934, as amended, including without limitation, statements on Form 3, Form 4 and Form 5 (including any amendments thereto) and (ii) in connection with any applications for EDGAR access codes, including without limitation the Form ID. The Power of Attorney shall remain in full force and effect until the undersigned is no longer required to file Forms 3, 4 and 5 with regard to his ownership of or transactions in securities of Patriot National, Inc., unless earlier revoked in writing. The undersigned acknowledges that Gex F. Richardson and Beth A. Crews are not assuming any of the undersigned's responsibilities to comply with Section 16 of the Securities Exchange Act of 1934. IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be executed as of this 25th day of May, 2017. Sign: /s/ John J. Rearer Name: John J. Rearer