| OMB APPROVAL |
| OMB Number: 3235-0362 |
| Expires: January 31, 2005 |
| Estimated average burden hours per response...1.0 |
UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, DC 20549
FORM 5
ANNUAL 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 box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b). |
| o | Form 3 Holdings Reported |
| o | Form 4 Transactions Reported |
| 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) |
|||||||
| MUTZ, GREGORY
T (Last) (First) (Middle) |
UICI
(NYSE:UCI) |
|||||||||||
| 4001 MCEWEN DR STE
200 |
4. | Statement for Month/Year | 5. | If Amendment, Date of Original (Month/Year) | ||||||||
| 12/02 |
|
|||||||||||
| (Street) | 6. | Relationship of Reporting Person(s) to Issuer (Check All Applicable) |
7. | Individual or Joint/Group
Reporting (Check Applicable Line) |
||||||||
| DALLAS, TX
75244 (City) (State) (Zip) |
x | 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) | |||||||||||
| President & CEO
|
||||||||||||
| * | 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 Securities Beneficially Owned at the End of Issuer's Fiscal Year (Instr. 3 and 4) |
6. | Ownership Form: Direct (D) or Indirect (I) (Instr. 4) |
7. | Nature
of Indirect Beneficial Ownership (Instr. 4) |
|||||||||
| Amount | (A) or (D) |
Price | ||||||||||||||||||||||
| Common Stock | 845,198 | D | ||||||||||||||||||||||
| Common Stock | J (1) | 2,720.1412 | A | 9,086.6738 | I | TTEES 401(k) | ||||||||||||||||||
| Common Stock | 808 | I | IRA | |||||||||||||||||||||
| Common Stock | 4,879 | I | CUST MINOR CHILDREN | |||||||||||||||||||||
| Common Stock | 255 | I | IRA MINOR CHILDREN | |||||||||||||||||||||
| Common Stock | 48,192 | I | RESIDUAL TRUST | |||||||||||||||||||||
| Common Stock | 16,064 | I | FAMILY TRUST(1) | |||||||||||||||||||||
| Common Stock | 34,836 | I | FAMILY TRUST(2) | |||||||||||||||||||||
| Common Stock | 43,395 | I | PARTNERSHIP | |||||||||||||||||||||
Page 2
| 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) |
||||||
| (A) | (D) | ||||||||||||||||
| Stock Option | $12.43 | ||||||||||||||||
| Stock Option | $6.625 | ||||||||||||||||
| Stock Option | $11.40 | ||||||||||||||||
| Stock Option | $15.00 | ||||||||||||||||
Page 3
| 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 at End of Year (Instr. 4) |
10. | Ownership 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 |
||||||||||||||
| 01/15/04 | Common Stock | 20,937 | D | ||||||||||||||
| 04/09/05 | Common Stock | 310,000 | D | ||||||||||||||
| 01/07/07 | Common Stock | 150,000 | D | ||||||||||||||
| 01/14/03 | Common Stock | 9,600 | D | ||||||||||||||
Explanation of Responses:
(1) J: Participant and Company matching ongoing contributions to 401(k) during Plan Year.
| /s/ Gregory T. Mutz | 02/07/03 | |
**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 provided is insufficient, see Instruction 6 for procedure. | |
Page 4