Insider filing report for Changes in Beneficial Ownership
- Schedule 13G & 13D forms are used to report a party's ownership of stock which exceeds 5% of a company's total stock issue.
- Schedule 13G is a shorter version of Schedule 13D with fewer reporting requirements.
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UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
SCHEDULE 13D
Under the Securities Exchange Act of 1934
(Amendment No. 4)*
Conifer Holdings, Inc.
(Name of Issuer)
Common Stock, no par value
(Title of Class of Securities)
20731J102
(CUSIP Number)
Conifer Holdings, Inc.
550 West Merrill Street, Suite 200
Birmingham, MI 48009
(248) 559-0840
(Name, Address and Telephone Number of Person Authorized to Receive Notices and Communications)
December 31, 2021
(Date of Event Which Requires Filing of this Statement)
If the filing person has previously filed a statement on Schedule 13G to report the acquisition that is the subject of this Schedule 13D, and is filing this schedule because of §§ 240.13d-1(e), 240.13d-1(f) or 240.13d-1(g), check the following box. ☐
Note: Schedules filed in paper format shall include a signed original and five copies of the schedule, including all exhibits. See Rule 13d-7 for other parties to whom copies are to be sent.
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The remainder of this cover page shall be filled out for a reporting person’s initial filing on this form with respect to the subject class of securities, and for any subsequent amendment containing information which would alter disclosures provided in a prior cover page. |
The information required on the remainder of this cover page shall not be deemed to be “filed” for the purpose of section 18 of the Securities Exchange Act of 1934 (“Act”) or otherwise subject to the liabilities of that section of the Act but shall be subject to all other provisions of the Act (however, see the Notes).
SCHEDULE 13D
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CUSIP No. 20731J102 |
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Page 2 of 4 |
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(1) |
Names of reporting persons
James G. Petcoff |
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(2) |
Check the appropriate box if a member of a group (see instructions)
(a) ☐ (b) ☐ |
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(3) |
SEC use only
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(4) |
Source of funds (see instructions)
PF |
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(5) |
Check if disclosure of legal proceedings is required pursuant to Items 2(d) or 2(e)
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(6) |
Citizenship or place of organization
United States of America |
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Number of |
(7) |
Sole voting power
2,650,420 |
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shares beneficially owned by |
(8) |
Shared voting power
0 |
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each reporting person |
(9) |
Sole dispositive power
2,650,420 |
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with: |
(10) |
Shared dispositive power
0 |
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(11) |
Aggregate amount beneficially owned by each reporting person
2,650,420 |
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(12) |
Check if the aggregate amount in Row (11) excludes certain shares (see instructions)
☐ |
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(13) |
Percent of class represented by amount in Row (11)
27.3% |
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(14) |
Type of reporting person (see instructions)
IN |
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SCHEDULE 13D
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CUSIP No. 20731J102 |
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Page 3 of 4 |
Item 1.Security and Issuer
This Schedule 13D is being filed with respect to shares of Common Stock issued by Conifer Holdings, Inc., whose principal executive offices are at 550 West Merrill Street, Suite 200, Birmingham, MI 48009.
Item 2.Identity and Background
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(a) |
James G. Petcoff. |
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(b) |
The principal business address for Mr. Petcoff is 550 West Merrill Street, Suite 200, Birmingham, MI 48009. |
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(c) |
Mr. Petcoff is the Chairman and Chief Executive Officer of Conifer Holdings, Inc. |
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(d) |
During the last five years, Mr. Petcoff has not been convicted in a criminal proceeding (excluding traffic violations or similar misdemeanors). |
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(e) |
During the last five years, Mr. Petcoff has not been a party to a civil proceeding of a judicial or administrative body of competent jurisdiction where, as a result of such proceeding, he was or he became subject to a judgment, decree or final order enjoining future violations of, or prohibiting or mandating activities subject to, federal or state securities laws or finding any violation with respect to such laws. |
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(f) |
Mr. Petcoff is a citizen of the United States of America. |
Item 3.Source and Amount of Funds or Other Considerations
Not applicable.
Item 4.Purpose of Transaction
Not applicable.
Item 5.Interest in Securities of the Issuer
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(a) |
As of the time of this filing, Mr. Petcoff owns 2,650,420 shares of the Issuer’s Common Stock, or a 27.3% ownership interest of the Issuer’s Common Stock. |
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(b) |
As of the time of this filing, Mr. Petcoff has the sole power to vote or to direct the vote of 2,650,420 shares of the Issuer’s Common Stock. Mr. Petcoff has the sole power to dispose or to direct the disposition of 2,650,420 shares of the Issuer’s Common Stock. |
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(c) |
Not applicable. |
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(d) |
Not applicable. |
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(e) |
Not applicable. |
Item 6.Contracts, Arrangements, Understandings or Relationships with Respect to Securities of the Issuer
Except as set forth in this Schedule 13D, there are no contracts, arrangements, understandings or relationships among the Reporting Person and any other person, with respect to the securities of the Issuer.
Item 7.Material to be Filed as Exhibits
None.
SCHEDULE 13D
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CUSIP No. 20731J102 |
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Page 4 of 4 |
SIGNATURE
After reasonable inquiry and to the best of my knowledge and belief, I certify that the information set forth in this statement is true, complete and correct.
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Date: February 9, 2022 |
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Signature: /s/ James G. Petcoff
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Name/Title: James G. Petcoff, Chairman and Chief Executive Officer |