- Statement of Changes in Beneficial Ownership (4)
23 Dezember 2010 - 12:21AM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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3235-0287
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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(f) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
*
Fullington Robert S.
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2. Issuer Name
and
Ticker or Trading Symbol
Fortegra Financial Corp
[
FRF
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director
_____ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
EVP & Pres., Consecta
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(Last)
(First)
(Middle)
C/O FORTEGRA FINANCIAL CORPORATION, 100 WEST BAY STREET
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3. Date of Earliest Transaction
(MM/DD/YYYY)
12/22/2010
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(Street)
JACKSONVILLE, FL 32202
(City)
(State)
(Zip)
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4. 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 Acquired, Disposed of, or Beneficially Owned
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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock, par value $0.01 per share
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12/22/2010
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C
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1293
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A
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(4)
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58251
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D
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Common Stock, par value $0.01 per share
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12/22/2010
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S
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28435
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A
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$11
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29816
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D
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Common Stock, par value $0.01 per share
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12/22/2010
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C
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2107
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A
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(4)
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2107
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I
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See footnote
(1)
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Common Stock, par value $0.01 per share
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15750
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I
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See footnote
(2)
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Common Stock, par value $0.01 per share
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15750
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I
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See footnote
(3)
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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. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4)
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11. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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(A)
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(D)
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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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(4)
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12/22/2010
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C
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246
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(4)
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(4)
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Common Stock
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1293
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(4)
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0
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D
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Class A Common Stock, par value $0.01 per share
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(4)
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12/22/2010
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C
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401
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(4)
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(4)
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Common Stock
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2107
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(4)
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0
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I
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See footnote
(1)
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Explanation of Responses:
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(
1)
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Shares held by Fortegra Financial Corporation in a trust for the benefit of the reporting person.
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(
2)
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Held by the Robert S. Fullington Grantor Retained Annuity Trust.
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(
3)
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Held by the Robert S. Fullington GRAT II.
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(
4)
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The Class A Common Stock converted 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 had no expiration date.
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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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Fullington Robert S.
C/O FORTEGRA FINANCIAL CORPORATION
100 WEST BAY STREET
JACKSONVILLE, FL 32202
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EVP & Pres., Consecta
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Signatures
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/s/ John G. Short, Attorney-in-Fact
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12/22/2010
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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 4(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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