-----BEGIN PRIVACY-ENHANCED MESSAGE----- Proc-Type: 2001,MIC-CLEAR Originator-Name: webmaster@www.sec.gov Originator-Key-Asymmetric: MFgwCgYEVQgBAQICAf8DSgAwRwJAW2sNKK9AVtBzYZmr6aGjlWyK3XmZv3dTINen TWSM7vrzLADbmYQaionwg5sDW3P6oaM5D3tdezXMm7z1T+B+twIDAQAB MIC-Info: RSA-MD5,RSA, QYchlzEd1FeYJ4Ww73ucueC7Fa2TMMu14Fd++6SYCfoA4ZuAM2TSRn4mRcecXjgm yLBpaRoN4zeSa84xwpkIOw== 0000897069-03-000030.txt : 20030106 0000897069-03-000030.hdr.sgml : 20030106 20030106162632 ACCESSION NUMBER: 0000897069-03-000030 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20030102 FILED AS OF DATE: 20030106 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: REPEDE RAYMOND C CENTRAL INDEX KEY: 0001195097 RELATIONSHIP: OFFICER FILING VALUES: FORM TYPE: 4 BUSINESS ADDRESS: STREET 1: COBALT CORP STREET 2: 401 WEST MICHIGAN ST CITY: MILWAUKEE STATE: WI ZIP: 53203 BUSINESS PHONE: 4142265000 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: COBALT CORP CENTRAL INDEX KEY: 0001062780 STANDARD INDUSTRIAL CLASSIFICATION: HOSPITAL & MEDICAL SERVICE PLANS [6324] IRS NUMBER: 391931212 STATE OF INCORPORATION: WI FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-14177 FILM NUMBER: 03505277 BUSINESS ADDRESS: STREET 1: 401 WEST MICHIGAN STREET CITY: MILWAUKEE STATE: WI ZIP: 53203-2896 BUSINESS PHONE: 4142266900 MAIL ADDRESS: STREET 1: 401 WEST MICHIGAN STREET CITY: MILWAUKEE STATE: WI ZIP: 52030-2896 FORMER COMPANY: FORMER CONFORMED NAME: UNITED WISCONSIN SERVICES INC DATE OF NAME CHANGE: 19981112 4 1 irm77.txt FORM 4 ------------------------------ OMB APPROVAL ------------------------------ OMB Number 3235-0287 Expires: January 31, 2005 Estimated average burden hours per response ....... 0.5 ------------------------------ UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C. 20549 FORM 4 STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 [_] 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* REPEDE, RAYMOND C. - -------------------------------------------------------------------------------- (Last) (First) (Middle) c/o Cobalt Corporation 401 West Michigan - -------------------------------------------------------------------------------- (Street) Milwaukee, WI 53203 - -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Issuer Name and Ticker or Trading Symbol COBALT CORPORATION (NYSE: CBZ) ________________________________________________________________________________ 3. IRS Identification Number of Reporting Person, if an Entity (Voluntary) ________________________________________________________________________________ 4. Statement for Month/Day/Year January 2, 2003 ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Day/Year) ================================================================================ 6. Relationship of Reporting Person(s) to Issuer (Check all applicable) [_] Director [_] 10% Owner [X] Officer (give title below) [_] Other (specify below) Vice President and Controller ________________________________________________________________________________ 7. 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 ================================================================================
5. 6. 2A. 4. Amount of Owner- Deemed Securities Acquired (A) or Securities ship 2. Execution 3. Disposed of (D) Beneficially Form: 7. Transaction Date, if Transaction (Instr. 3, 4 and 5) Owned Follow- Direct Nature of Date any Code ------------------------------- ing Reported (D) or Indirect 1. (Month/ (Month/ (Instr. 8) (A) Transaction(s) Indirect Beneficial Title of Security Day/ Day/ ------------ Amount or Price (Instr. 3 (I) Ownership (Instr. 3) Year) Year) Code V (D) and 4) (Instr.4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 1/2/03 A 1,900 A 1,900 D - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ==================================================================================================================================== 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). Persons who respond to the collection of information contained in this form are not required to respond (Over) unless the form displays a currently valid OMB control number. SEC 1474 (9-02)
FORM 4 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ====================================================================================================================================
10. 9. Owner- Number ship of Deriv- Form 2. ative of Conver- 5. 7. Secur- Deriv- 11. sion Number of Title and Amount ities ative Nature or 3A. Derivative 6. of Underlying 8. Benefi- Secur- of Exer- Deemed 4. Securities Date Securities Price cially ity: In- cise 3. Execu- Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of Owned Direct direct Price Trans- tion action or Disposed Expiration Date ---------------- Deriv- Following (D) or Bene- 1. of action Date, Code of(D) (Month/Day/Year) Amount ative Reported In- ficial Title of Deriv- Date if any (Instr. (Instr. 3, ---------------- or Secur- Trans- direct Owner- Derivative ative (Month/ (Month/ 8) 4 and 5) Date Expira- Number ity action(s) (I) ship Security Secur- Day/ Day/ ------ ------------ Exer- tion of (Instr (Instr (Instr (Instr (Instr. 3) ity Year) Year) Code V (A) (D) cisable Date Title Shares 5) 4) 4) 4) - ------------------------------------------------------------------------------------------------------------------------------------ Employee Stock Option (right to buy)(1) $18.00 9/16/03(2) 9/15/14 * 20,000 20,000 D - ------------------------------------------------------------------------------------------------------------------------------------ Employee Stock Option (right to buy)(1) $14.10 1/2/03 A 8,000 1/2/04(2) 12/31/15 * 8,000 8,000 D - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ==================================================================================================================================== Explanation of Responses: * Common Stock (1) Grant to reporting person of option to buy shares of common stock under the Cobalt Corporation Equity Incentive Plan. (2) The option vests in four equal annual installments beginning the first anniversary after the date of grant. RAYMOND C. REPEDE ** Intentional misstatements or omissions of facts constitute Federal Criminal Violations. /s/ Raymond C. Repede 01/06/03 ------------------------------------- ---------- See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). ** Signature of Reporting Person Date Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. Page 2
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