Statement of Changes in Beneficial Ownership (4)
29 November 2018 - 8:22AM
Edgar (US Regulatory)
FORM 4
[
X
]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0287
Estimated average burden
hours per response...
0.5
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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
*
GUERTIN SHAWN M
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2. Issuer Name
and
Ticker or Trading Symbol
AETNA INC /PA/
[
AET
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
_____ Director
_____ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
Exec. Vice President, CFO
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(Last)
(First)
(Middle)
AETNA INC., 151 FARMINGTON AVENUE
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3. Date of Earliest Transaction
(MM/DD/YYYY)
11/28/2018
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(Street)
HARTFORD, CT 06156
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_
X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Common Stock
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11/28/2018
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D
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11058
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D
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(1)
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0
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D
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Common Stock
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11/28/2018
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D
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11174
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D
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(1)
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0
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I
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By 2018 GRAT
(2)
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Common Stock
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11/28/2018
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D
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25000
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D
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(1)
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0
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I
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By 2018 CRUT
(3)
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Common Stock
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11/28/2018
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D
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634.7406
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D
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(1)
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0
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I
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By 401(k) Plan
(4)
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Table II - Derivative Securities Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4)
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11. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Stock Appreciation Rights
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$100.50
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11/28/2018
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D
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25715
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(5)
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(5)
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Common Stock
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25715
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(5)
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0
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D
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Stock Appreciation Rights
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$116.44
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11/28/2018
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D
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11415
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(6)
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(6)
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Common Stock
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11415
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(6)
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0
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D
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Stock Appreciation Rights
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$103.45
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11/28/2018
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D
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55376
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(7)
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(7)
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Common Stock
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55376
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(7)
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0
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D
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Stock Appreciation Rights
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$125.27
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11/28/2018
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D
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81864
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(8)
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(8)
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Common Stock
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81864
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(8)
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0
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D
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Performance Stock Units
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(9)
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11/28/2018
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D
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23780
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(9)
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(9)
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Common Stock
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23780
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(9)
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0
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D
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Performance Stock Units
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(10)
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11/28/2018
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D
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10179
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(10)
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(10)
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Common Stock
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10179
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(10)
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0
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D
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Restricted Stock Units
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(11)
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11/28/2018
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D
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23940
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(11)
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(11)
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Common Stock
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23940
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(11)
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0
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D
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Explanation of Responses:
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(1)
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Converted pursuant to the merger agreement (the "Merger Agreement") between CVS Health Corporation ("CVS Health") and Aetna Inc. ("Aetna") into $145 in cash and 0.8378 shares of CVS Health Common Stock for each share of Aetna Common Stock.
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(2)
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Represents shares held in 2018 Grantor Retained Annuity Trust ("GRAT") for which the Reporting Person is sole trustee.
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(3)
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Represents shares held in 2018 Charitable Remainder Unitrust ("CRUT") for which the Reporting Person is sole trustee.
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(4)
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Represents the pro rata portion of the stock portion of the Aetna Common Stock Fund held by Reporting Person on October 31, 2018 pursuant to the Aetna Inc. 401(k) Plan. The information is based on information provided by the Plan Trustee as of that date.
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(5)
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Represents Stock Appreciation Rights ("SARs") granted under the Aetna Inc. 2010 Stock Incentive Plan (the "Plan") on March 2, 2015. These SARs were canceled pursuant to the terms of the Merger Agreement in exchange for an amount in cash for each SAR equal to (a) $145 plus (b) 0.8378 multiplied by the average of the volume weighted averages of the trading prices of CVS Health Common Stock on each of the five consecutive trading days ending on the trading day two trading days prior to the closing date, less (c) the exercise price (the "SAR Amount").
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(6)
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Represents SARs granted under the Plan on September 24, 2015. These SARs were canceled pursuant to the terms of the Merger Agreement in exchange for an amount in cash for each SAR equal to the SAR Amount.
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(7)
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Represents SARs granted under the Plan on February 19, 2016. Of this amount, 50% had vested. Each vested SAR was canceled pursuant to the terms of the Merger Agreement in exchange for an amount in cash equal to the SAR Amount. Each unvested SAR was converted to a CVS Health SAR pursuant to the terms of the Merger Agreement.
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(8)
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Represents SARs granted under the Plan on February 17, 2017, of which 33.3% had vested. Each vested SAR was canceled pursuant to the terms of the Merger Agreement in exchange for an amount in cash for each SAR equal to the SAR Amount. Each unvested SAR was converted to a CVS Health SAR pursuant to the terms of the Merger Agreement.
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(9)
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Represents Performance Stock Units ("PSUs") earned at a specified level in conjunction with the change in control of Aetna and pursuant to the terms of the relevant PSU award agreement. The PSUs were originally granted under the Plan on February 19, 2016. These PSUs were converted to time-vesting CVS Health Restricted Stock Units ("RSUs") pursuant to the terms of the Merger Agreement.
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(10)
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PSUs earned at a specified level in conjunction with the change in control of Aetna and pursuant to the terms of the relevant PSU award agreement. The PSUs were originally granted under the Plan on February 17, 2017. These PSUs were converted to time-vesting CVS Health RSUs pursuant to the terms of the Merger Agreement.
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(11)
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RSUs under the Plan granted on March 2, 2018. These RSUs were converted to CVS Health RSUs pursuant to the terms of the Merger Agreement.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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GUERTIN SHAWN M
AETNA INC.
151 FARMINGTON AVENUE
HARTFORD, CT 06156
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Exec. Vice President, CFO
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Signatures
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/s/ Shawn M. Guertin, by Adam F. McAnaney, Attorney-in-fact
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11/28/2018
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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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 control number.
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