0001742429-24-000004.txt : 20240319 0001742429-24-000004.hdr.sgml : 20240319 20240319175522 ACCESSION NUMBER: 0001742429-24-000004 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20240306 FILED AS OF DATE: 20240319 DATE AS OF CHANGE: 20240319 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Chacon Quiros Juan Jose CENTRAL INDEX KEY: 0001742429 ORGANIZATION NAME: FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38593 FILM NUMBER: 24765310 MAIL ADDRESS: STREET 1: C/O MOTIVA USA LLC STREET 2: 16192 COASTAL HIGHWAY CITY: LEWES STATE: DE ZIP: 19958 FORMER NAME: FORMER CONFORMED NAME: Quiros Juan Jose Chacon DATE OF NAME CHANGE: 20180601 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: ESTABLISHMENT LABS HOLDINGS INC. CENTRAL INDEX KEY: 0001688757 STANDARD INDUSTRIAL CLASSIFICATION: ORTHOPEDIC, PROSTHETIC & SURGICAL APPLIANCES & SUPPLIES [3842] ORGANIZATION NAME: 08 Industrial Applications and Services IRS NUMBER: 981436377 STATE OF INCORPORATION: D8 FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: BUILDING B15 AND 25 COYOL FREE ZONE CITY: ALAJUELA STATE: G2 ZIP: 20101 BUSINESS PHONE: 50624342400 MAIL ADDRESS: STREET 1: BUILDING B15 AND 25 COYOL FREE ZONE CITY: ALAJUELA STATE: G2 ZIP: 20101 4 1 wk-form4_1710885312.xml FORM 4 X0508 4 2024-03-06 0 0001688757 ESTABLISHMENT LABS HOLDINGS INC. ESTA 0001742429 Chacon Quiros Juan Jose C/O MOTIVA USA LLC 16192 COASTAL HIGHWAY LEWES DE 19958 1 1 0 0 Chief Executive Officer 0 Common Shares 2024-03-06 4 A 0 13519 0 A 225735 D Common Shares 1128264 I See Footnote Stock Option (Right to buy) 49.25 2024-03-06 4 A 0 19236 0 A 2034-03-06 Common Shares 19236 19236 D Represents an award of stock units under the Issuer's 2018 Equity Incentive Plan. One-fourth of the shares subject to the award shall vest on March 6, 2025 and each one-year anniversary thereafter, subject to the Reporting Person continuing as a service provider through such date. The shares are held by Sariel LLC. The Reporting Person is a shareholder of Sariel LLC and has voting and dispositive power over the shares owned by Sariel LLC. The Reporting Person disclaims beneficial ownership of the shares held by Sariel LLC, except to the extent of his pecuniary interest therein. One-fourth of the shares subject to the option shall vest on March 6, 2025 and each one-year anniversary thereafter, subject to the Reporting Person continuing as a service provider through each such date. /s/ Rajbir S. Denhoy, Chief Financial Officer, by power of attorney 2024-03-19