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DOMA HOLDINGS, INC.
Date Filed :
Jul 30, 2021
View Exhibits
SEC FORM 4
SEC Form 4
FORM 4
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
OMB APPROVAL
OMB Number:
3235-0287
Estimated average burden
hours per response:
0.5
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
1. Name and Address of Reporting Person
*
EIN MARK
(Last)
(First)
(Middle)
101 MISSION ST. SUITE 740
(Street)
SAN FRANCISCO
CA
94105
(City)
(State)
(Zip)
2. Issuer Name
and
Ticker or Trading Symbol
Doma Holdings, Inc.
[
DOMA
]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X
Director
10% Owner
Officer (give title below)
Other (specify below)
3. Date of Earliest Transaction (Month/Day/Year)
07/28/2021
4. 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 Acquired, Disposed of, or Beneficially Owned
1. Title of Security (Instr. 3)
2. Transaction Date (Month/Day/Year)
2A. Deemed Execution Date, if any (Month/Day/Year)
3. Transaction Code (Instr. 8)
4. Securities Acquired (A) or Disposed Of (D) (Instr. 3, 4 and 5)
5. Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr. 3 and 4)
6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
7. Nature of Indirect Beneficial Ownership (Instr. 4)
Code
V
Amount
(A) or (D)
Price
Common stock
(1)
07/28/2021
M
4,101,051
A
(1)
4,101,051
I
By Capitol Acquisition Management V, LLC
Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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 Securities Underlying Derivative Security (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: 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
Class B common stock
(2)
07/28/2021
D
1,235,344
(2)
(2)
Common stock
1,235,344
(2)
4,101,051
I
By Capitol Acquisition Management V, LLC
Class B common stock
(1)
07/28/2021
M
4,101,051
(1)
(1)
Common stock
4,101,051
(1)
0
I
By Capitol Acquisition Management V, LLC
Explanation of Responses:
1. The Class B common stock automatically converted into shares of Class A common stock of the Issuer following the completion of the merger by and among, Capitol, Capitol V Merger Sub, Inc. and Former Doma (the "Merger") on a one-for-one basis, subject to adjustment, which such closing occurred on July 28, 2021. At the completion of the Merger, Class A common stock was renamed common stock.
2. The Class B common stock was forfeited and cancelled for no consideration pursuant to the Sponsor Support Agreement between Capitol Acquisition Management V LLC ("Capitol Management V"), Capitol Investment Corp V. ("Capitol"), Doma Holdings, Inc., which was formerly known as States Title Holding, Inc. ("Former Doma") and certain other parties thereto, dated March 2, 2021.
Remarks:
Exhibit 24 - Power of Attorney
/s/ Christian Ameri, as Attorney-in-Fact for Mark D. Ein.
07/30/2021
** 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 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).
Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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 Number.
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