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*
(Street)
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2. Date of Event Requiring Statement
(Month/Day/Year) 11/30/2004 |
3. Issuer Name and Ticker or Trading Symbol
WELLPOINT INC [ WLP ] |
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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5. If Amendment, Date of Original Filed
(Month/Day/Year) |
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Table I - Non-Derivative Securities Beneficially Owned | |||
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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 | 114 | I | 401(k) |
Common Stock | 46,319 | I | The Herman-Rasiej Family Trust Account |
Table II - Derivative Securities Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) | |||||||
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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 | ||||
Deferred Comp Stock Units | (1) | (1) | Common Stock | 7,329 | $0 | D | |
Deferred Comp Stock Units | (2) | (2) | Common Stock | 2,568 | $0 | D | |
Deferred Comp Stock Units | (3) | (3) | Common Stock | 10,600 | $0 | D | |
Employee Stock Option (right to buy) | (4) | 06/04/2008 | Common Stock | 2,884 | $29.28 | D | |
Employee Stock Option (right to buy) | (4) | 06/04/2008 | Common Stock | 432 | $38.39 | D | |
Employee Stock Option (right to buy) | (4) | 06/04/2008 | Common Stock | 367 | $34.81 | D | |
Employee Stock Option (right to buy) | (4) | 06/03/2011 | Common Stock | 59,520 | $34.92 | D | |
Employee Stock Option (right to buy) | (4) | 06/04/2008 | Common Stock | 6,148 | $34.92 | D | |
Employee Stock Option (right to buy) | (4) | 01/31/2011 | Common Stock | 80,114 | $38.9 | D | |
Employee Stock Option (right to buy) | (4) | 06/04/2008 | Common Stock | 5 | $39.72 | D | |
Employee Stock Option (right to buy) | (4) | 02/11/2009 | Common Stock | 3,519 | $39.86 | D | |
Employee Stock Option (right to buy) | (4) | 06/04/2008 | Common Stock | 3,747 | $43.47 | D | |
Employee Stock Option (right to buy) | (4) | 06/04/2008 | Common Stock | 11,252 | $47.54 | D | |
Employee Stock Option (right to buy) | (4) | 06/03/2008 | Common Stock | 3,502 | $49.04 | D | |
Employee Stock Option (right to buy) | (4) | 02/10/2009 | Common Stock | 2,036 | $49.04 | D | |
Employee Stock Option (right to buy) | (5) | 02/06/2012 | Common Stock | 119,824 | $51.21 | D | |
Employee Stock Opton (right to buy) | (4) | 02/10/2010 | Common Stock | 1,822 | $54.85 | D | |
Employee Stock Option (right to buy) | (4) | 01/31/2011 | Common Stock | 17,711 | $54.85 | D | |
Employee Stock Option (right to buy) | (6) | 02/04/2013 | Common Stock | 68,200 | $55.1 | D | |
Employee Stock Option (right to buy) | (4) | 02/10/2010 | Common Stock | 9,036 | $79.18 | D | |
Employee Stock Option (right to buy) | (4) | 01/31/2011 | Common Stock | 6,749 | $79.18 | D | |
Employee Stock Option (right to buy) | (4) | 02/04/2013 | Common Stock | 36,586 | $79.18 | D | |
Employee Stock Option (right to buy) | (7) | 01/25/2014 | Common Stock | 79,360 | $82.06 | D | |
Employee Stock Option (right to buy) | (4) | 02/10/2009 | Common Stock | 8,467 | $87.72 | D | |
Employee Stock Option (right to buy) | (4) | 02/06/2012 | Common Stock | 10,157 | $87.72 | D | |
Employee Stock Option (right to buy) | (4) | 02/04/2013 | Common Stock | 17,118 | $87.72 | D | |
Employee Stock Option (right to buy) | (4) | 02/10/2010 | Common Stock | 3,244 | $87.72 | D | |
Employee Stock Option (right to buy) | (4) | 01/31/2011 | Common Stock | 1,138 | $87.72 | D |
Explanation of Responses: |
1. Deferred share right grant made in the Company's Comprehensive Executive Non-qualified Retirement Plan and awarded pursuant to the Company's 1999 Stock Incentive Plan. The deferred shares are fully vested. |
2. Deferred share right grant made in the Company's Comprehensive Executive Non-qualified Retirement Plan and awarded pursuant to the Company's 1999 Stock Incentive Plan. The deferred shares will vest on March 15, 2005. |
3. Deferred share right grant made in the Company's Comprehensive Executive Non-qualified Retirement Plan and awarded pursuant to the Company's 1999 Stock Incentive Plan. The deferred shares will vest in three equal annual installments beginning January 26, 2005, January 26, 2006 and January 26, 2007. |
4. These shares are fully vested. |
5. The options vested with respect to 97,504 shares and 22,320 options will vest on February 7, 2005. |
6. The options will vest in three equal installments on February 5, 2005, August 5, 2005 and February 6, 2006. |
7. The options are vested with respect to 13,226 shares and 66,134 options will vest in five equal installments on January 26, 2005, July 26, 2005, January 26, 2006, July 26, 2006 and January 26, 2007. |
Remarks: |
Nancy Purcell, Attorney-in-fact | 12/02/2004 | |
** 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). | ||
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. |