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*
WHITE MOUNTAINS INSURANCE GROUP LTD

(Last) (First) (Middle)
23 SOUTH MAIN STREET, SUITE 3B

(Street)
HANOVER NH 03755

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
10/28/2020
3. Issuer Name and Ticker or Trading Symbol
MediaAlpha, Inc. [ MAX ]
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)
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)
CLASS A COMMON STOCK 24,142,096(1) I See Footnote(2)
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
Explanation of Responses:
1. Pursuant the offering reorganization completed immediately prior to completion of the initial public offering of MediaAlpha, Inc. (the "Issuer") contemplated by the reorganization agreement, dated October 27, 2020, among the Issuer, QL Holdings LLC, White Mountains Investments (Luxembourg) S.a r.l., Guilford Holdings, Inc. and other parties named therein, White Mountains Investments (Luxembourg) S.a r.l. contributed all of the outstanding capital stock of Guilford Holdings, Inc. to the Issuer in exchange for shares of Class A common stock, par value 0.01$ per share, of the Issuer.
2. Includes 24,142,096 share of Class A Common Stock owned directly by White Mountains Investments (Luxembourg) S.a r.l. White Mountains Investments (Luxembourg) S.a r.l. is a wholly owned indirect subsidiary of White Mountains Insurance Group, Ltd. White Mountains Insurance Group, Ltd. has indirect pecuniary interest in the securities held by White Mountains Investments (Luxembourg) S.a r.l. Consequently, White Mountains Insurance Group, Ltd. is deemed to beneficially own the securities held directly by White Mountains Investments (Luxembourg) S.a r.l. The board of directors and senior officers of White Mountains Insurance Group, Ltd. disclaim beneficial ownership with respect to such securities.
Remarks:
Joint/Group Beneficial Owners: Bridge Holdings (Bermuda) Ltd. - A.S. Cooper Building, 26 Reid Street, Hamilton HM 11 Bermuda (a wholly owned direct subsidiary of White Mountains Insurance Group, Ltd.) WM International Holdings Ltd - 18 St. Swithin's Lane, London EC4N 8AD United Kingdom (a wholly owned direct subsidiary of Bridge Holdings (Bermuda) Ltd.) White Mountains Investments (Luxembourg) S.a.r.l. - 1, rue Hildegard von Bingen, L-1282 Luxembourg (a wholly owned direct subsidiary of WM International Holdings Ltd)
White Mountains Insurance Group, Ltd., by Robert L. Seelig, its EVP and General Counsel, /s/ Robert L. Seelig 10/27/2020
Bridge Holdings (Bermuda) Ltd., by Kevin Pearson, its Vice President, /s/ Kevin Pearson 10/27/2020
WM International Holdings Ltd, by Matthew Molton, its Director, /s/ Matthew Molton 10/27/2020
White Mountains Investments (Luxembourg) S.a.r.l., Societe a responsabilite limitee, registered office: 1, rue Hildegard von Bingen, L-1282 Luxembourg, R.C.S. Luxembourg: B 167.137, by Manfred Schneider, its Manager, /s/ Manfred Schneider 10/27/2020
** 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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