SEC FORM 3/A SEC Form 3
FORM 3 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
 
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1. Name and Address of Reporting Person*
Olsen Ted

(Last) (First) (Middle)
C/O GOOSEHEAD INSURANCE, INC.
1500 SOLANA BLVD, BUILDING 4, SUITE 4500

(Street)
WESTLAKE TX 76262

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
09/21/2020
3. Issuer Name and Ticker or Trading Symbol
Goosehead Insurance, Inc. [ GSHD ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
Officer (give title below) X Other (specify below)
Member of 10% owner group
5. If Amendment, Date of Original Filed (Month/Day/Year)
09/18/2020
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
Table I - Non-Derivative Securities Beneficially Owned
1. Title of Security (Instr. 4) 2. Amount of Securities Beneficially Owned (Instr. 4) 3. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 4. Nature of Indirect Beneficial Ownership (Instr. 5)
Table II - Derivative Securities Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative Security (Instr. 4) 2. Date Exercisable and Expiration Date (Month/Day/Year) 3. Title and Amount of Securities Underlying Derivative Security (Instr. 4) 4. Conversion or Exercise Price of Derivative Security 5. Ownership Form: Direct (D) or Indirect (I) (Instr. 5) 6. Nature of Indirect Beneficial Ownership (Instr. 5)
Date Exercisable Expiration Date Title Amount or Number of Shares
Employee Stock Options (right to buy)(1) (2) 01/02/2029 Class A Common Stock 25,000 26.29 D
Explanation of Responses:
1. This amendment is being filed in order to correct the exercisability dates and exercise price disclosed on the originally filed Form 3
2. One third (1/3rd) of the shares subject to the option shall vest and become exercisable, subject to continued employment, on January 2, 2021, January 2, 2022 and January 2, 2023, respectively; provided, that all shares subject to the option will vest and become exercisable if the reporting person's employment is terminated without "cause" or for "good reason" (each as defined in either the reporting person's option award agreement or the issuer's omnibus incentive plan) within six month following a "change in control" (as defined in the issuer's omnibus incentive plan).
/s/ P. Ryan Langston, as Attorney-in-Fact for Ted Olsen 09/21/2020
** Signature of Reporting Person Date
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
* If the form is filed by more than one reporting person, see Instruction 5 (b)(v).
** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
Note: 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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