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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 |
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number. | SEC 1474 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
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Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Stock Appreciation RIghts | $ 4.72 | 06/08/2015 | A | 25,000 | (2) | 06/08/2022 | Class A Common Stock | 25,000 | $ 0 | 25,000 | D | ||||
Stock Appreciation Rights | $ 11.75 | (3) | 10/28/2020 | Class A Common Stock | 175,000 | 175,000 | D |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
Petrizzo Michael A. Jr. C/O HEALTH INSURANCE INNOVATIONS, INC. 15438 N. FLORIDA AVE., SUITE 201 TAMPA, FL 33613 |
Exec VP, Gen. Counsel & Secy |
/s/ Michael A. Petrizzo, Jr. | 06/10/2015 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(b)(v). |
** | Intentional misstatements or omissions of facts constitute Federal Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
(1) | Includes shares of restricted stock granted pursuant to the Issuer's Long Term Incentive Plan which have fully vested pursuant to the terms of a separation agreement between the Reporting Person and the Issuer. |
(2) | These stock-settled stock appreciation rights were granted under the Issuer's Long-Term Incentive Plan and will vest upon successful completion of Reporting Person's employment transition period, which is expected to be August 31, 2015. |
(3) | Stock Appreciation Rights awarded pursuant to the issuer's Long Term Incentive Plan which have already vested or are scheduled to vest (excluding 25,000 of the rights) on the Reporting Person's last day of employment with the Issuer, which is anticipated to be August 31, 2015. |