0001593968-21-000832.txt : 20210305
0001593968-21-000832.hdr.sgml : 20210305
20210305183226
ACCESSION NUMBER: 0001593968-21-000832
CONFORMED SUBMISSION TYPE: 4
PUBLIC DOCUMENT COUNT: 2
CONFORMED PERIOD OF REPORT: 20210305
FILED AS OF DATE: 20210305
DATE AS OF CHANGE: 20210305
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: Smith Michael R.
CENTRAL INDEX KEY: 0001699809
FILING VALUES:
FORM TYPE: 4
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38046
FILM NUMBER: 21720032
MAIL ADDRESS:
STREET 1: 225 20TH STREET
CITY: ROCK ISLAND
STATE: IL
ZIP: 61201
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: ICC Holdings, Inc.
CENTRAL INDEX KEY: 0001681903
STANDARD INDUSTRIAL CLASSIFICATION: FIRE, MARINE & CASUALTY INSURANCE [6331]
IRS NUMBER: 813359409
STATE OF INCORPORATION: PA
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 225 20TH STREET
CITY: ROCK ISLAND
STATE: IL
ZIP: 61201
BUSINESS PHONE: 309-793-1700
MAIL ADDRESS:
STREET 1: 225 20TH STREET
CITY: ROCK ISLAND
STATE: IL
ZIP: 61201
4
1
primary_01.xml
PRIMARY DOCUMENT
X0306
4
2021-03-05
0001681903
ICC Holdings, Inc.
ICCH
0001699809
Smith Michael R.
225 20TH ST
ROCK ISLAND
IL
61201-8810
false
true
false
false
Chief Financial Officer
Common Stock
2021-03-05
4
M
false
428
14.41
A
2356
D
Common Stock
2021-03-05
4
F
false
148
14.41
D
2208
D
Common Stock
10500
I
401(k)
Common Stock
8300
I
IRA
Common Stock
709.7840
I
By ESOP
Common Stock
1400
I
401(k)
Common Stock
795.1674
I
By ESOP
Common Stock
351
I
401(k)
Common Stock
202
I
401(k)
Common Stock
9971
I
IRA
Common Stock
5000
I
IRA
Common Stock
727.2373
I
By ESOP
Common Stock
9
I
IRA
Common Stock
866
I
By ESOP
Restricted Stock Unit
0
2021-03-05
4
M
false
428
14.41
D
ICC Holdings, Inc. Common Stock
428
0
D
RSU with 3 Year Periodic vesting schedule
No exercise price for this type of award
No exercisable date for this type of award
No expiration date for this type of award
/s/Kathleen S. Springer, Attorney in Fact
2021-03-05
EX-24
2
smithpoa.htm
EX-24 DOCUMENT
Limited Power of Attorney
POWER OF ATTORNEY
Know all by these presents, that the undersigned hereby constitutes and
appoints each of Kathleen Springer, Julia B. Suiter, Sunjeet S. Gill and
Stephanie R. Hager or any of them signing singly, and with full power of
substitution, the undersigned's true and lawful attorney in fact to:
(1) prepare, execute in the undersigned's name and on the undersigned's
behalf, and submit to the U.S. Securities and Exchange Commission (the
"SEC") a Form ID, including amendments thereto, and any other documents
necessary or appropriate to obtain codes and passwords enabling the
undersigned to make electronic filings with the SEC of reports required by
Section 16(a) of the Securities Exchange Act of 1934 or any rule or
regulation of the SEC;
(2) execute for and on behalf of the undersigned, in the undersigned's
capacity as a director of ICC Holdings, Inc. (the "Company"), Forms 3, 4,
and 5 in accordance with Section 16(a) of the Securities Exchange Act of
1934 and the rules thereunder;
(3) do and perform any and all acts for and on behalf of the undersigned
which may be necessary or desirable to complete and execute any such Form
3, 4, or 5, complete and execute any amendment or amendments thereto, and
timely file such form with the SEC and any stock exchange or similar
authority; and
(4) take any other action of any type whatsoever in connection with the
foregoing which, in the opinion of such attorney in fact, may be of benefit
to, in the best interest of, or legally required by, the undersigned, it
being understood that the documents executed by such attorney in fact on
behalf of the undersigned pursuant to this Power of Attorney shall be in
such form and shall contain such terms and conditions as such attorney in
fact may approve in such attorney in fact's discretion.
The undersigned hereby grants to each such attorney in fact full power and
authority to do and perform any and every act and thing whatsoever
requisite, necessary, or proper to be done in the exercise of any of the
rights and powers herein granted, as fully to all intents and purposes as
the undersigned might or could do if personally present, with full power of
substitution or revocation, hereby ratifying and confirming all that such
attorney in fact, or such attorney in fact's substitute or substitutes,
shall lawfully do or cause to be done by virtue of this power of attorney
and the rights and powers herein granted. The undersigned acknowledges
that the foregoing attorneys in fact, in serving in such capacity at the
request of the undersigned, are not assuming, nor is the Company assuming,
any of the undersigned's responsibilities to comply with Section 16 of the
Securities Exchange Act of 1934.
This 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 respect to
the undersigned's holdings of and transactions in securities issued by the
Company, unless earlier revoked by the undersigned in a signed writing
delivered to the foregoing attorneys in fact.
IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to
be executed as of this 1st day of March 2017.
/s/ Michael R. Smith