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
 
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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*
Osborne Ian

(Last) (First) (Middle)
C/O 317 UNIVERSITY AVE, SUITE 200

(Street)
PALO ALTO CA 94301

(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
CLOVER HEALTH INVESTMENTS, CORP. /DE [ CLOV ]
5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director X 10% Owner
Officer (give title below) X Other (specify below)
FORMER PRESIDENT AND DIRECTOR
3. Date of Earliest Transaction (Month/Day/Year)
01/07/2021
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
Class A Common Stock 01/07/2021 A 5,000,000 A $10 5,000,000 I By Hedosophia Public Investments Limited(1)
Class A Common Stock 01/07/2021 M 20,500,000 A (2) 25,500,000 I By SCH Sponsor III LLC(3)
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 ordinary share (2) 01/07/2021 M 20,500,000 (2) (2) Class A Common Stock 20,500,000 $0.00 0 I By SCH Sponsor III LLC(3)
Explanation of Responses:
1. On the basis of the reporting person's relationship with Hedosophia Public Investments Limited, the reporting person may be deemed a beneficial owner of the shares of the Issuer's Class A common stock, par value $0.0001 per share ("Class A Shares"), held by Hedosophia Public Investments Limited. The reporting person disclaims beneficial ownership of the Shares held by Hedosophia Public Investments Limited, except to the extent of his pecuniary interest therein.
2. On January 7, 2021, the Social Capital Hedosophia Holdings Corp. III ("SCH" and the former name of the Issuer) consummated its initial business combination (the "Business Combination") with Clover Health Investments, Corp. In connection with the consummation of the Business Combination, each share of Class B ordinary share, par value $0.0001 per share, of SCH automatically converted into one Class A Share.
3. A majority of the voting interests of SCH Sponsor III LLC ("Sponsor") are held by ChaChaCha SPAC C LLC ("ChaChaCha"). Messrs. Chamath Palihapitiya and Ian Osborne and ChaChaCha may be deemed to beneficially own the Class A Shares held by the Sponsor on the basis of their direct or indirect interests in the Sponsor or their shared control over the Sponsor, as the case may be. Each of Mr. Palihapitiya, Mr. Osborne and ChaChaCha disclaims beneficial ownership of the Class A Shares held by the Sponsor, except to the extent of such person's pecuniary interest therein.
Remarks:
/s/ Ian Osborne 01/11/2021
** 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).
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