SEC FORM 3 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*
O'Connor John Terry

(Last) (First) (Middle)
1500 SOLANA BOULEVARD
SUITE 4500

(Street)
WESTLAKE TX 76262

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
06/02/2023
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)
General Counsel
5. If Amendment, Date of Original Filed (Month/Day/Year)
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) 05/02/2032 Class A Common Stock 20,000 57.49 D
Employee Stock Options (right to buy) (2) 01/03/2033 Class A Common Stock 20,000 35.25 D
Explanation of Responses:
1. One third (1/3rd) of the option, which represents the right to purchase a total of 20,000 shares, will vest and become exercisable, subject to continued employment, on each of the second, third and fourth anniversaries of the grant date, which was May 2, 2022.
2. One third (1/3rd) of the option, which represents the right to purchase a total of 20,000 shares, will vest and become exercisable, subject to continued employment, on each of the second, third and fourth anniversaries of the grant date, which was January 3, 2023.
Remarks:
/s/ John Terry O'Connor 06/02/2023
** 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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