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*
Rock Island Investors, LLC

(Last) (First) (Middle)
1230 PEACHTREE STREET NE; SUITE 3600

(Street)
ATLANTA GA 30309

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
03/24/2017
3. Issuer Name and Ticker or Trading Symbol
ICC Holdings, Inc. [ ICCH ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director X 10% Owner
Officer (give title below) Other (specify below)
5. If Amendment, Date of Original Filed (Month/Day/Year)
03/28/2017
6. Individual or Joint/Group Filing (Check Applicable Line)
Form filed by One Reporting Person
X 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)
Common Stock 400,000(1) D
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
1. Name and Address of Reporting Person*
Rock Island Investors, LLC

(Last) (First) (Middle)
1230 PEACHTREE STREET NE; SUITE 3600

(Street)
ATLANTA GA 30309

(City) (State) (Zip)
1. Name and Address of Reporting Person*
Leardo Patrick R.

(Last) (First) (Middle)
1230 PEACHTREE STREET NE; SUITE 3600

(Street)
ATLANTA GA 30309

(City) (State) (Zip)
Explanation of Responses:
1. These securities are owned directly by Rock Island Investors, LLC. This Form 3/A is being filed to amend the original Form 3 filed by Rock Island Investors, LLC and Patrick R. Leardo to reflect Rock Island Investors, LLC's pecuniary interest in all securities it owns directly. Mr. Leardo is exempt by virtue of Rule 16a-1(a)(1)(vii) of the Securities Exchange Act of 1934.
Rock Island Investors, LLC, By: /s/ John Luckett, Jr., its Authorized Representative 12/01/2021
/s/ Patrick R. Leardo 12/01/2021
** 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 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).
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