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*
COLBY DAVID C

(Last) (First) (Middle)
120 MONUMENT CIRCLE

(Street)
INDIANAPOLIS IN 46204

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
11/30/2004
3. Issuer Name and Ticker or Trading Symbol
WELLPOINT INC [ WLP ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
EVP
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)
Common Stock 921 I 401(k)
Common Stock 3,366 I Irrevocable Trust
Common Stock 252,665 I Colby Family Trust
Common Stock 14,142 D
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
Deferred Comp Stock Units (1) (1) Common Stock 13,736 $0 D
Deferred Comp Stock Units (2) (2) Common Stock 2,860 $0 D
Deferred Comp Stock Units (3) (3) Common Stock 10,600 $0 D
Employee Stock Option (right to buy) (4) 08/31/2007 Common Stock 13,682 $21.93 D
Employee Stock Option (right to buy) (4) 02/10/2010 Common Stock 111,600 $27.57 D
Employee Stock Option (right to buy) (4) 02/10/2009 Common Stock 45,136 $28.5 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) 01/31/2011 Common Stock 114,576 $38.9 D
Employee Stock Option (right to buy) (5) 02/06/2012 Common Stock 133,920 $51.21 D
Employee Stock Option (right to buy) (6) 02/04/2013 Common Stock 142,600 $55.1 D
Employee Stock Option (right to buy) (7) 01/25/2014 Common Stock 104,160 $82.06 D
Employee Stock Option (right to buy) (4) 02/10/2009 Common Stock 59,240 $87.72 D
Employee Stock Option (right to buy) (4) 02/11/2008 Common Stock 53,331 $87.72 D
Employee Stock Option (right to buy) (4) 08/31/2007 Common Stock 121,398 $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 options are fully vested.
5. The options are vested with respect to 111,600 shares and 22,320 options will vest on February 7, 2005.
6. The options are vested with respect to 71,301 shares and 23,767 options will vest on February 5, 2005, 23,767 on August 5, 2005 and 23,765 options will vest on February 5, 2006.
7. The options are vested with respect to 17,360 shares and 86,800 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.