0001726978-23-000081.txt : 20230628
0001726978-23-000081.hdr.sgml : 20230628
20230628184037
ACCESSION NUMBER: 0001726978-23-000081
CONFORMED SUBMISSION TYPE: 3
PUBLIC DOCUMENT COUNT: 1
CONFORMED PERIOD OF REPORT: 20230626
FILED AS OF DATE: 20230628
DATE AS OF CHANGE: 20230628
REPORTING-OWNER:
OWNER DATA:
COMPANY CONFORMED NAME: SLJ 2023 Grantor Retained Annuity Trust
CENTRAL INDEX KEY: 0001983108
STATE OF INCORPORATION: TX
FISCAL YEAR END: 1231
FILING VALUES:
FORM TYPE: 3
SEC ACT: 1934 Act
SEC FILE NUMBER: 001-38466
FILM NUMBER: 231053799
BUSINESS ADDRESS:
STREET 1: 1500 SOLANA BOULEVARD
STREET 2: SUITE 4500
CITY: WESTLAKE
STATE: TX
ZIP: 76262
BUSINESS PHONE: 214-838-5500
MAIL ADDRESS:
STREET 1: 1500 SOLANA BOULEVARD
STREET 2: SUITE 4500
CITY: WESTLAKE
STATE: TX
ZIP: 76262
ISSUER:
COMPANY DATA:
COMPANY CONFORMED NAME: Goosehead Insurance, Inc.
CENTRAL INDEX KEY: 0001726978
STANDARD INDUSTRIAL CLASSIFICATION: INSURANCE AGENTS BROKERS & SERVICES [6411]
IRS NUMBER: 000000000
STATE OF INCORPORATION: DE
FISCAL YEAR END: 1231
BUSINESS ADDRESS:
STREET 1: 1500 SOLANA BLVD
STREET 2: BUILDING 4, SUITE 4500
CITY: WESTLAKE
STATE: TX
ZIP: 76262
BUSINESS PHONE: 214-838-5500
MAIL ADDRESS:
STREET 1: 1500 SOLANA BLVD
STREET 2: BUILDING 4, SUITE 4500
CITY: WESTLAKE
STATE: TX
ZIP: 76262
3
1
wk-form3_1687992027.xml
FORM 3
X0206
3
2023-06-26
0
0001726978
Goosehead Insurance, Inc.
GSHD
0001983108
SLJ 2023 Grantor Retained Annuity Trust
1500 SOLANA BOULEVARD, SUITE 4500
WESTLAKE
TX
76262
0
0
1
1
Member of 10% owner group
Class B Common Stock
161094
D
LLC Units in Goosehead Financial, LLC
0
Class A Common Stock
161094
D
The reporting person disclaims beneficial ownership of the securities reported herein except to the extent of its pecuniary interest in them.
Each LLC Unit, together with a share of Class B common stock, may be converted by the holder into one share of Class A common stock at any time. The LLC Units do not expire.
By virtue of being party to a Voting Agreement, dated February 24, 2021 (the "Voting Agreement"), the reporting person on this Form 3 may be deemed to be a member of a "group" for purposes of Section 13(d) of the Securities Exchange Act of 1934, as amended, with respect to the securities reported herein with the other parties who continue to be bound by the Voting Agreement, which such "group" beneficially owns, in the aggregate, more than 10% of the outstanding shares of Class A Common Stock. Together with the reporting person on this Form 3, the parties to the Voting Agreement are Mark and Robyn Jones Descendants Trust 2014, Mark E. Jones, Robyn Jones, Lanni Romney, Lindy Langston, Camille Peterson, Desiree Coleman, Adrienne Jones, Mark Jones Jr., Lannie Elaine Romney Family Trust 2014, Lindy Jean Langston Family Trust 2014, Camille LaVaun Peterson Family Trust 2014, Desiree Robyn Coleman Family Trust 2014, Adrienne Morgan Jones Family Trust 2014, Mark Evan Jones Jr. Family Trust 2014, Serena Jones, P. Ryan Langston, SLJ Dynasty Trust, Jones 2020 Irrevocable Trust, Ryan Langston 2021 Family Trust, Nathan Scott Romney, Nathan Romney 2021 Family Trust, Lindy Langston Spousal Lifetime Access Trust, Lanni Romney Spousal Lifetime Access Trust, CP Descendants' Trust, and Chick & The Bear Irrevocable Trust.
/s/ Mark E. Jones as Attorney-in-Fact for SLJ 2023 Grantor Retained Annuity Trust
2023-06-28