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