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Filing Details

Accession Number:: 0001209191-15-086122
Form Type:: 4
Zero Holdings:: No
Publication Time:: 2015-12-18 16:43:22
Reporting Period:: 2015-12-16

Filing Date:: 2015-12-18
Accepted Time:: 2015-12-18 16:43:22
SEC Url:: Form 4 Filing

Issuer

Cik	Name	Symbol	Sector (SIC)	IRS No
1619917	Patriot National Inc.	PN	Insurance Agents, Brokers & Service (6411)	464151376

Insiders

Cik	Name	Reported Address	Insider Title	Director	Officer	Large Shareholder	Other
1480753	M. Steven Mariano	C/O Patriot National, Inc. 401 E. Las Olas Blvd., Suite 1650 Fort Lauderdale FL 33301	See Remarks	Yes	Yes	Yes	No

Reported Non-Derivative Transactions

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Sec. Name	Acquisiton - Disposition	Date	Amount	Price	Remaning Holdings	Equity Swap Involved	Form Type	Code	Nature of Ownership	Explanation
Common Stock	Disposition	2015-12-16	2,500,000	$0.00	12,066,175	No	4	S	Direct

Equity Swap Involved	Form Type	Code	Nature of Ownership	Explanation
No	4	S	Direct

Reported Derivative Transactions

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Sec. Name	Sec. Type	Acquisiton - Disposition	Date	Amount	Price	Amount - 2	Price - 2
Common Stock	Obligation to Sell	Disposition	2015-12-16	1,250,000	$0.00	1,250,000	$0.00

Remaning Holdings	Exercise Date	Expiration Date	Equity Swap Involved	Transaction Form Type	Transaction Code	Nature of Ownership
1,250,000			No	4	D	Direct

Reported Non-Derivative Holdings

Sec. Name	Remaning Holdings	Nature of Ownership	Explanation
Common Stock	1,307,398	Indirect	By Steven M. Mariano Trust
Common Stock	1,014,607	Indirect	By Corporation

Footnotes

Pursuant to the terms of a Securities Purchase Agreement dated as of December 13, 2015 (the "Purchase Agreement"), by and among the Issuer, the Reporting Person and the purchasers named therein (the "Purchasers"), the Reporting Person sold to the Purchasers an aggregate of 2,500,000 shares of issuer common stock ("Common Stock") for an aggregate purchase price of $30 million. Additionally, pursuant to the Purchase Agreement, the Issuer issued and sold to the Purchasers (i) 666,666 shares of Common Stock and prepaid Series B warrants for 1,000,000 shares of Common Stock (the "Series B Warrants"), and (ii) Series A warrants to purchase up to an aggregate of 2,083,333 shares of Common Stock (the "Series A Warrants", and together with the Series B Warrants, the "Warrants"), for an aggregate purchase price of approximately $20 million. The transaction described herein (the "Transaction") closed on December 16, 2015.
On December 13, 2015, the Issuer and the Reporting Person entered into an agreement (the "Stock Back-to-Back Agreement") pursuant to which the Issuer will repurchase a number of shares of Common Stock owned by the Reporting Person equal to 60% of the shares of Common Stock to be issued by the Issuer to the Purchasers in connection with the exercise by Purchasers of the Warrants.
This obligation to sell under the Stock Back-to-Back Agreement relates to the Series A Warrants. The Series A Warrants are exercisable at the lower of $15 per share or a variable exercise price described therein. The Series A Warrants are exercisable beginning on July 1, 2016 and expire on June 30, 2018.