SEC Form 4 · accession 0000950103-18-005875
Goosehead Insurance, Inc. · GSHD
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Robyn Mary Elizabeth Jones
Director · 10% Owner · Other
Period of report
May 1, 2018
Accepted (ET)
May 3, 2018 · 8:51 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 | 757,890 | $0.00 | A | 757,890 | D | |
| Class A Common StockF2 | May 1, 2018 | A | 1,748,281 | $0.00 | A | 1,748,281 | I | By Mark and Robyn Jones Descendants Trust 2014 |
| Class B Common StockF3 | May 1, 2018 | A | 171,633 | $0.01 | A | 171,633 | D | |
| Class B Common StockF4 | May 1, 2018 | A | 13,404,339 | $0.01 | A | 13,404,339 | I | By Mark and Robyn Jones Descendants Trust 2014 |
| Class B Common StockF4 | May 1, 2018 | A | 297,734 | $0.01 | A | 297,734 | I | By Lanni Elaine Romney Family Trust 2014 |
| Class B Common StockF4 | May 1, 2018 | A | 297,734 | $0.01 | A | 297,734 | I | By Lindy Jean Langston Family Trust 2014 |
| Class B Common StockF4 | May 1, 2018 | A | 297,734 | $0.01 | A | 297,734 | I | By Camille LaVaun Peterson Family Trust 2014 |
| Class B Common StockF4 | May 1, 2018 | A | 297,734 | $0.01 | A | 297,734 | I | By Desiree Robyn Coleman Family Trust 2014 |
| Class B Common StockF4 | May 1, 2018 | A | 297,734 | $0.01 | A | 297,734 | I | Adrienne Morgan Jones Family Trust 2014 |
| Class B Common StockF4 | May 1, 2018 | A | 297,734 | $0.01 | A | 297,734 | I | Mark Evan Jones, Jr. Family Trust 2014 |
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, LLCF5,F6 | $0.00 | May 1, 2018 | A | 171,633 | A | — | — | Class A Common Stock | 171,633 | 171,633 | D |
| LLC Units in Goosehead Financial, LLCF4,F6 | $0.00 | May 1, 2018 | A | 13,404,339 | A | — | — | Class A Common Stock | 13,404,339 | 13,404,339 | I |
| LLC Units in Goosehead Financial, LLCF4,F6 | $0.00 | May 1, 2018 | A | 297,734 | A | — | — | Class A Common Stock | 297,734 | 297,734 | I |
| LLC Units in Goosehead Financial, LLCF4,F6 | $0.00 | May 1, 2018 | A | 297,734 | A | — | — | Class A Common Stock | 297,734 | 297,734 | I |
| LLC Units in Goosehead Financial, LLCF4,F6 | $0.00 | May 1, 2018 | A | 297,734 | A | — | — | Class A Common Stock | 297,734 | 297,734 | I |
| LLC Units in Goosehead Financial, LLCF4,F6 | $0.00 | May 1, 2018 | A | 297,734 | A | — | — | Class A Common Stock | 297,734 | 297,734 | I |
| LLC Units in Goosehead Financial, LLCF4,F6 | $0.00 | May 1, 2018 | A | 297,734 | A | — | — | Class A Common Stock | 297,734 | 297,734 | I |
| LLC Units in Goosehead Financial, LLCF4,F6 | $0.00 | May 1, 2018 | A | 297,734 | A | — | — | Class A Common Stock | 297,734 | 297,734 | 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. The reported securities do not include an equal number of shares of Class A common stock held directly by the reporting person's husband (a director and officer of the issuer) for which the reporting person disclaims beneficial ownership.
- 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"). These securities do not include an equal number of shares of Class B common stock held directly by the reporting person's husband (a director and officer of the issuer) for which the reporting person disclaims beneficial ownership.
- 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.
- F5These 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. These securities do not include an equal number of LLC Units held directly by the reporting person's husband (a director and officer of the issuer) for which the reporting person disclaims beneficial ownership.
- F6Each 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.