-----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, LL+4j+jBM5W3/lhINW0Pyl73V1CBahF12eVF2cYt6BOgUGHHKzZV+M2dcZrNAyqA 4cYWaGwrVqFmo2cyF66SYw== 0001019687-03-000182.txt : 20030206 0001019687-03-000182.hdr.sgml : 20030206 20030206135515 ACCESSION NUMBER: 0001019687-03-000182 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20021116 FILED AS OF DATE: 20030206 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: ICU MEDICAL INC/DE CENTRAL INDEX KEY: 0000883984 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 330022692 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 000-19974 FILM NUMBER: 03542240 BUSINESS ADDRESS: STREET 1: 951 CALLE AMANECER CITY: SAN CLEMENTE STATE: CA ZIP: 92769 BUSINESS PHONE: 9493662183 MAIL ADDRESS: STREET 1: 951 CALLE AMANELER CITY: SANCLEMENTE STATE: CA ZIP: 92769 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: KOVALCHIK MICHAEL T CENTRAL INDEX KEY: 0001073390 RELATIONSHIP: DIRECTOR FILING VALUES: FORM TYPE: 4 BUSINESS ADDRESS: STREET 1: C/O ICU MEDICAL INC STREET 2: 951 CALLE AMANECER CITY: SAN CLEMENTE STATE: CA ZIP: 92673 BUSINESS PHONE: 949366283 MAIL ADDRESS: STREET 1: C/O ICU MEDICAL INC STREET 2: 951 CALLE AMANECER CITY: SAN CLEMENTE STATE: CA ZIP: 92673 4 1 kovalchik_f4-111602.txt ------------------------------ 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, DC 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). |_| Form 3 Holdings Reported |_| Form 4 Transactions Reported (Print of Type Responses) ________________________________________________________________________________ 1. Name and Address of Reporting Person* Kovalchik, III, M.D. Michael T. - -------------------------------------------------------------------------------- (Last) (First) (Middle) 951 Calle Amanecer - -------------------------------------------------------------------------------- (Street) San Clemente CA 92673 - -------------------------------------------------------------------------------- (City) (State) (Zip) ________________________________________________________________________________ 2. Issuer Name and Ticker or Trading Symbol ICU Medical, Inc. (ICUI) ________________________________________________________________________________ 3. I.R.S. Identification Number of Reporting Person, if an entity (voluntary) ________________________________________________________________________________ 4. Statement for Month/Day/Year ________________________________________________________________________________ 5. If Amendment, Date of Original (Month/Day/Year) November 16, 2002 ________________________________________________________________________________ 6. Relationship of Reporting Person(s) to Issuer (Check all applicable) |X| Director |_| 10% Owner | | Officer (give title below) |_| Other (specify below) ----------------------- ________________________________________________________________________________ 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. Amount of 6. 4. Securities Owner- Securities Acquired (A) or Beneficially ship 2A. 3. Disposed of (D) Owned Form: 7. 2. Deemed Transaction (Instr. 3, 4 and 5) Following Direct Nature of Trans- Execution Code ------------------------------- Reported (D) or Indirect 1. action Date, if (Instr. 8) (A) Transaction(s) Indirect Beneficial Title of Security Date any ------------ or (Instr. 3 & (I) Ownership (Instr. 3) (mm/dd/yy) (mm/dd/yy) Code V Amount (D) Price Instr.4) (Instr.4) (Instr.4) - ------------------------------------------------------------------------------------------------------------------------------------ Common Stock held by Self, 3/15/02 J 2,587 7,762 D Self and Spouse Jointly - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ (J) 3:2 stock split in form of 50% stock dividend. - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
FORM 4 (continued) Table II -- Derivative Securities Acquired, Disposed of, or Beneficially Owned (e.g., puts, calls, warrants, options, convertible securities) ================================================================================
9. Number 10. of Owner- deriv- ship ative Form 2. Secur- of Conver- 5. 7. ities Deriv- 11. sion Number of Title and Amount Bene- ative Nature or Derivative 6. of Underlying 8. ficially Secur- of Exer- 3A. 4. Securities Date Securities Price Owned ity: In- cise Deemed Trans- Acquired (A) Exercisable and (Instr. 3 and 4) of Follow- Direct direct Price 3. Execut- action or Disposed Expiration Date ---------------- Deriv- ing (D) or Bene- 1. of Trans- ion Code of(D) (Month/Day/Year) Amount ative Reported In- ficial Title of Deriv- action Date if (Instr. (Instr. 3, ---------------- or Secur- Trans- direct Owner- Derivative ative Date any 8) 4 and 5) Date Expira- Number ity action(s) (I) ship Security Secur- (mm/dd/ (mm/dd/ ------ ------------ Exer- tion of (Instr. (Instr. (Instr. (Instr. (Instr. 3) ity yy) yy) Code V (A) (D) cisable Date Title Shares 5) 4) 4) 4) - ------------------------------------------------------------------------------------------------------------------------------------ Options to 28.1833 05/02/02 11/02/12 Common N/A 1,875 D Acquire Stock Common Stock (Grant 11/2/01) - ------------------------------------------------------------------------------------------------------------------------------------ Options to 39.2500 11/16/02 01/02/10 Common N/A 15,000 D Acquire Stock Common Stock (Grant 5/16/02) - ------------------------------------------------------------------------------------------------------------------------------------ Options to 36.3050 02/16/03 08/16/13 Common N/A 1,875 D Acquire Stock Common Stock (Grant 8/16/02) - ------------------------------------------------------------------------------------------------------------------------------------ Options to 39.5550 11/16/02 A 1,875 05/16/03 05/16/13 Common N/A 1,875 D Acquire Stock Common Stock (Grant 11/16/02) - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ ====================================================================================================================================
Explanation of Responses: /s/ Michael T. Kovalchik, III, M.D. 11/16/02 - --------------------------------------------- ----------------------- **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). Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure. -----END PRIVACY-ENHANCED MESSAGE-----