-----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, KjJEHYaR2ryzUcj91TmKLgaWaBPzOXg1pBw8mrNk9xY/xurrPyz8NG5LfDNtFywW +X5GgWxWn9IJwrLDf6JbTA== 0000892569-03-000512.txt : 20030224 0000892569-03-000512.hdr.sgml : 20030224 20030224170816 ACCESSION NUMBER: 0000892569-03-000512 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20030220 FILED AS OF DATE: 20030224 REPORTING-OWNER: COMPANY DATA: COMPANY CONFORMED NAME: NG DOMINIC CENTRAL INDEX KEY: 0001201236 RELATIONSHIP: DIRECTOR FILING VALUES: FORM TYPE: 3 BUSINESS ADDRESS: STREET 1: EAST WEST BANK STREET 2: 415 HUHTINGTON DR. CITY: SAN MARINO STATE: CA ZIP: 91108 SUBJECT COMPANY: COMPANY DATA: COMPANY CONFORMED NAME: PACIFICARE HEALTH SYSTEMS INC /DE/ CENTRAL INDEX KEY: 0001027974 STANDARD INDUSTRIAL CLASSIFICATION: HOSPITAL & MEDICAL SERVICE PLANS [6324] IRS NUMBER: 954591529 STATE OF INCORPORATION: DE FISCAL YEAR END: 0930 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 000-21949 FILM NUMBER: 03577979 BUSINESS ADDRESS: STREET 1: 3120 LAKE CENTER DRIVE CITY: SANTA ANA STATE: CA ZIP: 92704 BUSINESS PHONE: 7148255200 MAIL ADDRESS: STREET 1: 3120 LAKE CENTER DRIVE CITY: SANTA ANA STATE: CA ZIP: 92704 FORMER COMPANY: FORMER CONFORMED NAME: N T HOLDINGS INC DATE OF NAME CHANGE: 19961204 3 1 a87920ae3.htm FORM 3 DOMINIC NG
 

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UNITED STATES
SECURITIES AND EXCHANGE COMMISSION

Washington, D.C. 20549

FORM 3

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

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


1. Name and Address of Reporting
Person*
2. Date of Event Requiring Statement
(Month/Day/Year)
3. I.R.S. Identification Number of Reporting
Person, if an entity
(Voluntary)
  Ng, Dominic
(Last) (First) (Middle)
  02/20/03
 
 
 
     
  5995 Plaza Drive

(Street)
4. Issuer Name and Ticker or Trading Symbol 5. Relationship of Reporting Person(s)
to Issuer
(Check All Applicable)
    PacifiCare Health Systems, Inc.
  x  Director o  10% Owner
      o  Officer (give title below)
    6. If Amendment, Date of Original
(Month/Day/Year)
  o  Other (specify below)
  Cypress, CA 90630
(City)         (State)         (Zip)
 

   
      7. Individual or Joint/Group Filing
(Check Applicable Line)
        x Form Filed by One Reporting Person
                o Form Filed by More than One Reporting Person

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).


 


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)

           

           

           

           

           

           

           

           

           

           

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.

Page 2


 

                           

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 of
Derivative Security:
Direct (D) or Indirect (I)

(Instr. 5)
6. Nature of
Indirect
Beneficial
Ownership

(Instr. 5)

      Date
Exer-
cisable
Expi-
ration
Date
 
Title
Amount
or
Number
of Shares
           

Non-Qualified Stock Option (right to buy)   (1) 02/20/13   Common stock 25,000.000 $22.1700   D  

       

         

         

         

         

         

         

         

         

Explanation of Responses:

/s/ Dominic Ng   02/20/03

**Signature of Reporting Person
 
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 display a currently valid OMB Number.

Page 3


 

         
Ng, Dominic
5995 Plaza Drive
Cypress, CA 90630
  PacifiCare Health Systems, Inc. 02/20/03   Page 4 of 4 pages

(1)   Granted under the Amended and Restated 2000 Non-Employee Directors Stock Plan of PacifiCare Health Systems, Inc., which is a 16b-3(c) plan. The Option is fully vested and exercisable on date of grant which is 2/20/03; however, the underlying shares of PacifiCare common stock acquired upon exercise of the Option may not be sold within the first six months of the date of grant.
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