SEC Form 4 · accession 0000950103-18-005867
Goosehead Insurance, Inc. · GSHD
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Michael C. Colby
Officer — President and COO
Period of report
May 1, 2018
Accepted (ET)
May 3, 2018 · 8:16 pm EDT
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001726978
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Class A Common StockF1 | May 1, 2018 | A | 92,631 | $0.00 | A | 92,631 | D | |
| Class A Common StockF2 | May 1, 2018 | A | 238,402 | $0.00 | A | 238,402 | I | By Colby 2014 Family Trust |
| Class B Common StockF3 | May 1, 2018 | A | 967,085 | $0.01 | A | 967,085 | D | |
| Class B Common StockF4 | May 1, 2018 | A | 771,732 | $0.01 | A | 771,732 | I | By Colby 2014 Family Trust |
| Class B Common StockF4 | May 1, 2018 | A | 43,217 | $0.01 | A | 43,217 | I | By Preston Michael Colby 2014 Trust |
| Class B Common StockF4 | May 1, 2018 | A | 43,217 | $0.01 | A | 43,217 | I | By Lyla Kate Colby 2014 Trust |
Table II — derivative securities
| Security | Conv. / exercise price | Date | Code | Shares | A/D | Exercisable | Expires | Underlying | Underlying shares | Owned after | D/I |
|---|---|---|---|---|---|---|---|---|---|---|---|
| LLC Units in Goosehead Financial, LLCF3,F5 | $0.00 | May 1, 2018 | A | 967,085 | A | — | — | Class A Common Stock | 967,085 | 967,085 | D |
| LLC Units in Goosehead Financial, LLCF4,F5 | $0.00 | May 1, 2018 | A | 771,732 | A | — | — | Class A Common Stock | 771,732 | 771,732 | I |
| LLC Units in Goosehead Financial, LLCF4,F5 | $0.00 | May 1, 2018 | A | 43,217 | A | — | — | Class A Common Stock | 43,217 | 43,217 | I |
| LLC Units in Goosehead Financial, LLCF4,F5 | $0.00 | May 1, 2018 | A | 43,217 | A | — | — | Class A Common Stock | 43,217 | 43,217 | I |
Explanation of responses
- F1These securities were acquired by the reporting person in connection with the closing of the issuer's initial public offering, in exchange for notes of the issuer held by the reporting person.
- F2These securities were acquired by the trust in connection with the closing of the issuer's initial public offering, in exchange for notes of the issuer held by the trust.
- F3These securities were acquired through the conversion immediately prior to the issuer's initial public offering of historical interests held by the reporting person in Goosehead Financial, LLC ("Goosehead Financial").
- F4These securities were acquired through the conversion immediately prior to the issuer's initial public offering of historical interests held by the trust in Goosehead Financial.
- F5Each LLC Unit, together with a share of Class B common stock, may be converted by the holder into one share of Class A common stock at any time. The LLC Units do not expire.