|
UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES 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(h) of the Investment Company Act of 1940 |
|
| ||||||||||||||||||||||||||||||||||||||
|
Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. | |||
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. | SEC 1474 (9-02) |
1. Title of Derivative Security (Instr. 3) |
2. Conversion or Exercise Price of Derivative Security | 3. Transaction Date (Month/Day/Year) | 3A. Deemed Execution Date, if any (Month/Day/Year) | 4. Transaction Code (Instr. 8) |
5. Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr. 3, 4, and 5) |
6. Date Exercisable and Expiration Date (Month/Day/Year) |
7. Title and Amount of Underlying Securities (Instr. 3 and 4) |
8. Price of Derivative Security (Instr. 5) |
9. Number of Derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4) |
10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4) |
11. Nature of Indirect Beneficial Ownership (Instr. 4) |
||||
Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | ||||||||
Series B Convertible Preferred Stock | (4) | 08/12/2005 | C | 167,758 (1) (2) | (4) | (4) | Common Stock | 1,883,590 (1) (2) | (4) | 0 | D | ||||
Series B Convertible Preferred Stock | (4) | 08/12/2005 | C | 25,000 (1) (3) | (4) | (4) | Common Stock | 276,753 (1) (3) | (4) | 0 | I | By High Ridge Capital Partners II, L.P. |
Reporting Owner Name / Address | Relationships | |||
Director | 10% Owner | Officer | Other | |
HRWCP 1 LP 20 LIBERTY STREET PO BOX 388 CHESTER, CT 06412 |
X | |||
High Ridge GP Holdings LLC 20 LIBERTY STREET PO BOX 388 CHESTER, CT 06412 |
X | |||
Long Trail Ventures LLC 20 LIBERTY STREET PO BOX 388 CHESTER, CT 06412 |
X |
/s/ Steven J. Tynan, Manager of General Partner | 08/16/2005 | |
**Signature of Reporting Person | Date | |
/s/ Steven J. Tynan, Manager | 08/16/2005 | |
**Signature of Reporting Person | Date | |
/s/ Steven J. Tynan, Manager | 08/16/2005 | |
**Signature of Reporting Person | Date |
* | If the form is filed by more than one reporting person, see Instruction 4(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). |
(1) | Each reporting person disclaims beneficial ownership of the reported securities except to the extent of its pro rata pecuniary interest therein. |
(2) | These shares are owned directly by HRWCP 1, L.P. and owned indirectly by High Ridge GP Holdings LLC and Long Trail Ventures LLC. |
(3) | These shares are owned directly by High Ridge Capital Partners II, L.P. and owned indirectly by Long Trail Ventures L.L.C. |
(4) | Represents shares of Common Stock of JRVR received upon automatic conversion of shares of Convertible Preferred Stock of JRVR. Each share of Series B Convertible Preferred Stock automatically converted into shares of Common Stock of JRVR immediately prior to the closing of the initial public offering of Common Stock of JRVR on August 12, 2005. Each share of Series B Convertible Preferred Stock converted into a number of shares of Common Stock of JRVR equal to the product of (A) the quotient of (i) the sum of (x) $100, representing the purchase price of each share of Series B Convertible Preferred Stock, plus (y) all accrued and unpaid dividends thereon, divided by (ii) $100, multiplied by (B) 10, to reflect the 10-for-1 stock split effected by JRVR immediately prior to the closing of the initial public offering of Common Stock of JRVR on August 12, 2005. |
Remarks: Exhibit List: Exhibit 99.1-Joint Filer Information. Exhibit 99.2-Joint Filer Information. |