4 1 a87158de4.htm FORM 4 PacifiCare Health Systems, Inc.
 

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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

o 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*		 2. Issuer Name and Ticker or Trading
Symbol		 3. I.R.S. Identification Number of Reporting
Person, if an entity (Voluntary)
  Konowiecki, Joseph S
(Last) (First) (Middle)		   PacifiCare Health Systems, Inc.
  
     
  5995 Plaza Drive
(Street)		 4. Statement for Month/Day/Year 5. If Amendment, Date of Original (Month/Day/Year)
    1/22/2003
  
     
    6. Relationship of Reporting Person(s)
to Issuer (Check All Applicable)		 7. Individual or Joint/Group Filing
(Check Applicable Line)
  Cypress, CA 90630
(City)        (State)        (Zip)		   o  Director o  10% Owner   x Form Filed by One Reporting Person
    x  Officer (give title below)   o Form Filed by More than One Reporting Person
    o  Other (specify below)  
     
     
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).

 

                                               
Table I — Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
1. Title of Security
(Instr. 3)		 2. Transaction
Date
(Month/Day/Year)		 2A. Deemed Execution
Date, if any
(Month/Day/Year)		 3. Transaction
Code
(Instr. 8)		 4. Securities Acquired (A) or
Disposed of (D)
(Instr. 3, 4 and 5)		 5. Amount of Sec-
urities Beneficially
Owned Following
Reported Trans-
action(s)
(Instr. 3 and 4)		 6. Ownership
Form:
Direct (D) or
Indirect (I)
(Instr. 4)		 7. Nature of
Indirect
Beneficial
Ownership
(Instr. 4)
              Code V   Amount (A)
or
(D)		 Price          
  Common Stock   07/31/02     J V     687.629
(1)		   A   $20.1200         D  
  Common Stock   01/22/03     A     20,000.000
(2)		   A       95,572.629     D  
  Common Stock                   240.000     I   By 401(k) plan
  Common Stock                   166.000     I   by Son 1
  Common Stock                   166.000     I   by Son 2
  Common Stock                   166.000     I   By Son 3
  Common Stock                   500.000     I   by Trust
                         
                         
                         
                         
                         
                         
                         

     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 control number.

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Table II — Derivative Securities Acquired, Disposed of, or Beneficially Owned
  (e.g., puts, calls, warrants, options, convertible securities)
1. Title of Derivative
Security
(Instr. 3)		 2. Conversion or Exercise
Price of Derivative
Security		 3. Transaction
Date
(Month/Day/Year)		 3A.  Deemed Execution
Date, if any
(Month/Day/Year)		 4. Transaction
Code
(Instr. 8)		 5. Number of Derivative Securities
Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
                      Code V   (A) (D)
  Common Stock Units              
  Non-Qualified Stock Option (right to buy)     $16.0800          
  Non-Qualified Stock Option (right to buy)     $28.5500     01/22/03     A   60,000.000
  Non-Qualified Stock Option (right to buy)     $38.0000          
  Non-Qualified Stock Option (right to buy)     $40.5000          
  Non-Qualified Stock Option (right to buy)     $45.3125          
  Non-Qualified Stock Option (right to buy)     $53.8750          
  Non-Qualified Stock Option (right to buy)     $66.7500          
  Non-Qualified Stock Option (right to buy)     $67.0000          
  Non-Qualified Stock Option (right to buy)     $69.5000          
  Non-Qualified Stock Option (right to buy)     $71.5938          
  Non-Qualified Stock Option (right to buy)     $72.8750          
  Non-Qualified Stock Option (right to buy)     $80.3750          
  Non-Qualified Stock Option (right to buy)     $83.7500          
  Non-Qualified Stock Option (right to buy)     $92.5000          
  Non-Qualified Stock Option (right to buy)     $114.0000     10/06/02     V
(4) 		V   50,000.000
               
               
               
               
               
               

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Table II — Derivative Securities Acquired, Disposed of, or Beneficially Owned — Continued
(e.g., puts, calls, warrants, options, convertible securities)
6. Date Exercisable and
Expiration Date
(Month/Day/Year)		 7. Title and Amount
of Underlying Securities
(Instr. 3 and 4)		 8. Price of Derivative
Security
(Instr. 5)		 9. Number of Derivative Securities
Beneficially Owned Following
Reported Transaction(s)
(Instr. 4)		 10. Ownership Form of
Derivative Security:
Direct (D) or
Indirect (I)
(Instr. 4)		 11. Nature of
Indirect
Beneficial
Ownership
(Instr. 4)
  Date
Exercisable		 Expiration
Date		   Title Amount or
Number of
Shares		                        
    Common Stock 8,750.000           8,750.000     D  
  01/02/12   Common Stock 300,000.000           300,000.000     D  
  (3) 01/22/13   Common Stock 60,000.000           60,000.000     D  
  12/15/02   Common Stock 5,000.000           5,000.000     D  
  12/16/03   Common Stock 14,000.000           14,000.000     D  
  11/05/09   Common Stock 35,000.000           35,000.000     D  
  08/24/10   Common Stock 35,000.000           35,000.000     D  
  12/21/04   Common Stock 25,000.000           25,000.000     D  
  10/02/07   Common Stock 7,500.000           7,500.000     D  
  10/11/05   Common Stock 15,000.000           15,000.000     D  
  04/22/09   Common Stock 15,000.000           15,000.000     D  
  03/27/08   Common Stock 10,000.000           10,000.000     D  
  11/21/06   Common Stock 15,000.000           15,000.000     D  
  02/15/07   Common Stock 25,000.000           25,000.000     D  
  10/07/07   Common Stock 50,000.000           50,000.000     D  
  10/06/02   Common Stock 50,000.000           0.000     D  
                   
                   
                   
                   
                   
                   

Explanation of Responses:

(1) Includes 687 shares acquired under the PacifiCare Health Systems stock purchase plan in July 2002.

(2) The restricted stock units were granted on January 22, 2003 (the "Grant Date") pursuant to the 1996 Stock Option Plan for Officers and Key Employees of PacifiCare Health Systems, Inc., as amended, (the "Plan"). Each restricted stock unit entitles the recipient to receive a share of restricted stock after a four year deferral period. Within 45 days after the Grant Date, the recipient may elect to defer receipt of the restricted stock beyond the four year deferral period. In which case, the recipient shall receive the restricted stock on the earlier of the date specified in such election, or the date on which the recipient terminates his or her service as an employee of PacifiCare. The restricted stock is subject to forfeiture until certain restrictions, including continued employment, have lapsed. The forfeiture restrictions lapse in four cumulative annual installments each equal to 25 percent of the shares of restricted stock, commencing on the first anniversary of the Grant Date, and continuing on each of the next three successive anniversaries of the Grant Date.

(3) Granted under the 1996 Stock Option Plan for Officers and Key Employees of PacifiCare Health Systems, Inc., as amended, which is a Rule 16b-3 plan. The options become vested in four equal annual installments beginning on the first anniversary January 22, 2004.

(4) Options expired on 10/6/02.

- Beneficial holdings reflected on this report do not include changes in the reporting person's holdings of securities from participation in the issuer's qualified employee stock plan since the last filing of a report disclosing transactions related to such participation

   
/s/ Joseph S. Konowiecki
**Signature of Reporting Person		   1/23/03
Date

**   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.

     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 control number.

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