SEC Form 3 · accession 0000950103-18-006077
Goosehead Insurance, Inc. · GSHD
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owners
Camille Peterson
10% Owner · Other
Mark E. Jones Jr.
10% Owner · Other
Adrienne Jones
10% Owner · Other
Desiree Coleman
10% Owner · Other
Period of report
May 1, 2018
Accepted (ET)
May 10, 2018 · 7:09 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 B Common StockF1 | holding | — | — | — | 498,557 | D | ||
| Class B Common StockF2 | holding | — | — | — | 498,557 | D | ||
| Class B Common StockF3 | holding | — | — | — | 498,557 | D | ||
| Class B Common StockF4 | holding | — | — | — | 498,557 | D |
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,F1 | $0.00 | holding | — | — | — | — | — | Class A Common Stock | 498,557 | — | D |
| LLC Units in Goosehead Financial, LLCF5,F2 | $0.00 | holding | — | — | — | — | — | Class A Common Stock | 498,557 | — | D |
| LLC Units in Goosehead Financial, LLCF5,F3 | $0.00 | holding | — | — | — | — | — | Class A Common Stock | 498,557 | — | D |
| LLC Units in Goosehead Financial, LLCF5,F4 | $0.00 | holding | — | — | — | — | — | Class A Common Stock | 498,557 | — | D |
Explanation of responses
- F1These securities were acquired through the conversion immediately prior to the issuer's initial public offering of historical interests held by Camille Peterson in Goosehead Financial, LLC ("Goosehead Financial"). These securities are owned solely by Camille Peterson, who is a member of a "group" pursuant to a voting agreement with (and with respect to the securities reported in footnotes 2 through 4 hereof and which securities are owned by) Mark Evan Jones, Robyn Jones, Mark and Robyn Jones Descendants Trust 2014, Lanni Elaine Romney Family Trust 2014, Lindy Jean Langston Family Trust 2014, Camille Lavaun Peterson Family Trust 2014, Desiree Robyn Coleman Family Trust 2014, Adrienne Morgan Jones Family Trust 2014, Mark Evan Jones, Jr. Family Trust 2014, Serena Jones, Lanni Romney, Lindy Langston, Desiree Coleman, Adrienne Jones and Mark E. Jones, Jr. for purposes of Section 13(d) of the Exchange Act.
- F2These securities are owned solely by Desiree Coleman and were acquired through the conversion immediately prior to the issuer's initial public offering of historical interests held by Desiree Coleman in Goosehead Financial.
- F3These securities are owned solely by Adrienne Jones and were acquired through the conversion immediately prior to the issuer's initial public offering of historical interests held by Adrienne Jones in Goosehead Financial.
- F4These securities are owned solely by Mark E. Jones, Jr. and were acquired through the conversion immediately prior to the issuer's initial public offering of historical interests held by Mark E. Jones, Jr. 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.
Remarks
Each reporting person on the Form 3 is a member of a 10% owner group. However, as the group contains more than ten insiders, see the Form 3 for Mark & Robyn Jones Descendants Trust 2014 filed May 10, 2018 for the securities owned by additional members of the group.