- Initial Statement of Beneficial Ownership (3)
17 Dezember 2010 - 12:51AM
Edgar (US Regulatory)
FORM 3
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
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3235-0104
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February 28, 2011
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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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1. Name and Address of Reporting Person
*
Carroll John R
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2. Date of Event Requiring Statement (MM/DD/YYYY)
12/16/2010
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3. Issuer Name
and
Ticker or Trading Symbol
Fortegra Financial Corp [FRF]
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(Last)
(First)
(Middle)
C/O SUMMIT PARTNERS, L.P., 222 BERKELEY STREET, 18TH FLOOR
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4. Relationship of Reporting Person(s) to Issuer (Check all applicable)
__
X
__ Director
_____ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Street)
BOSTON, MA 02116
(City)
(State)
(Zip)
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5. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_
X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Beneficially Owned
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1.Title of Security
(Instr. 4)
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2. Amount of Securities Beneficially Owned
(Instr. 4)
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3. Ownership Form: Direct (D) or Indirect (I)
(Instr. 5)
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4. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Table II - Derivative Securities Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 4)
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2. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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3. Title and Amount of Securities Underlying Derivative Security
(Instr. 4)
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4. Conversion or Exercise Price of Derivative Security
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5. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 5)
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6. Nature of Indirect Beneficial Ownership
(Instr. 5)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Class A Common Stock, par value $0.01 per share
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(1)
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(1)
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Common Stock
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13987447
(2)
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(1)
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I
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See remarks.
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Explanation of Responses:
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(
1)
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The Class A Common Stock will convert into Common Stock of Fortegra Financial Corporation on a 1 for 5.25 basis immediately prior to the consummation of the initial public offering and has no expiration date.
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(
2)
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Shares are held as follows: 8,080,540 in the name of Summit Partners Private Equity Fund VII-A, L.P., 4,853,301 in the name of Summit Partners Private Equity Fund VII-B, L.P., 665,383 in the name of Summit Subordinated Debt Fund III-A, L.P., 346,614 in the name of Summit Subordinated Debt Fund III-B, L.P., and 41,609 in the name of Summit Investors VI, L.P.
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Remarks:
The entities mentioned in Footnote 2 collectively are referred to as the "Summit Entities." Summit Partners, L.P. is (i)
managing member of Summit Partners PE VII, LLC, which is the general partner of Summit Partners PE VII, L.P., which is the general partner
of Summit Partners Private Equity Fund VII-A, L.P. and Summit Partners Private Equity Fund VII-B, L.P., (ii) the managing member
of Summit Partners SD III, LLC, which is the general partner of Summit Partners SD III, L.P., which is the general partner of Summit
Subordinated Debt Fund III-A, L.P. and Subordinated Debt Fund III-B, L.P. and (iii) the managing member of Summit Partners VI (GP),
LLC, which is the general partner of Summit Partners VI (GP), L.P., which is the general partner of Summit Investors VI, L.P.
Summit Partners, L.P., through a two-person investment committee, has voting and dispositive authority over the shares held by the Summit
Entities, and therefore may beneficially own such shares. Mr. Carroll is a member of the general partner of Summit Partners,
L.P. Mr. Carroll disclaims beneficial ownership of the shares listed in Footnote 2, and this report shall not be deemed an admission
that Mr. Carroll is the beneficial owner of such shares for the purpose of Section 16 or for any other purpose, except, in each case,
to the extent of Mr. Carroll's pecuniary interest therein.
Exhibit List:
Exhibit 24 - Power of Attorney
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Carroll John R
C/O SUMMIT PARTNERS, L.P.
222 BERKELEY STREET, 18TH FLOOR
BOSTON, MA 02116
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X
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Signatures
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/s/ Robin Devereux, Power of Attorney for John Carroll
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12/16/2010
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 5(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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.
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