- -------- U.S. SECURITIES AND EXCHANGE COMMISSION -------------------------------- FORM 4 Washington, D.C. 20549 OMB APPROVAL - -------- -------------------------------- [ ] Check this box if no STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OMB Number: 3235-0287 longer subject to Expires: September 30, 1998 Section 16. Form 4 Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Estimated average burden or Form 5 obligations Section 17(a) of the Public Utility Holding Company Act of 1935 hours per response.......... 0.5 may continue. See or Section 30(f) of the Investment Company Act of 1940 -------------------------------- Instruction 1(b). (Print or Type Responses) - ----------------------------------------------------------------------------------------------------------------------------------- 1. Name and Address of 2. Issuer Name and Ticker or 6. Relationship of Reporting Person to Issuer Reporting Person* Trading Symbol (Check all applicable) Michael Kovalchik, MD ICU Medical, Inc. (ICUI) X Director 10% Owner - ---------------------------------------------------------------------------------- ---- ---- (Last) (First) (Middle) 3. IRS or Social 4. Statement for ____ Officer (give ____ Other (specify Security Number of Month/Year title below below) Reporting Person February 1999 951 Calle Amanecer (Voluntary) ---------------------- ------------------------------------------- - -------------------------------- 5. If Amendment, 7. Individual or Joint/Group Filing (Check (Street) Date of Original Applicable Line) (Month/Year) X Form filed by One Reporting Person San Clemente, CA 92673 ----- _____ Form filed by More than One Reporting Person - ----------------------------------------------------------------------------------------------------------------------------------- (City) (State) (Zip) Table I -- Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned - ----------------------------------------------------------------------------------------------------------------------------------- 1. Title of Security 2. Trans- 3. Trans- 4. Securities Acquired (A) 5. Amount of 6. Owner- 7. Nature of (Instr. 3) action action or Disposed of (D) Securities ship Indirect Date Code (Instr. 3, 4 and 5) Beneficially Form: Beneficial (Instr. 8) Owned at Direct Ownership (Month/ End of Month (D) or In- Day/ direct (I) Year) (Instr. 3 (Instr.4) (Instr. 4) and 4) ------------------------------------------------ Common Stock Code V Amount (A) or Price (D) - ------------------------------------------------------------------------------------------------------------------------------------ Self, Self and Spouse Jointly 2/3/99 S 1,200 D 18.75 - ------------------------------------------------------------------------------------------------------------------------------------ Self, Self and Spouse Jointly 2/10/99 S 1,000 D 20.06 6,175 D - ------------------------------------------------------------------------------------------------------------------------------------ By Self as Trustee for Children 2/19/99 S 800 D 20.00 - ------------------------------------------------------------------------------------------------------------------------------------ By Self as Trustee for Children 2/22/99 S 600 D 19.94 1,700 I(b) (a) - ------------------------------------------------------------------------------------------------------------------------------------ By Spouse in IRA 1,650 D(b) - ------------------------------------------------------------------------------------------------------------------------------------ By Nephrology Associates Pension Plan 3,250 I (a) - ------------------------------------------------------------------------------------------------------------------------------------ (**) As of 4/24/98 pursuant to Directors' Stock Award Plan - ------------------------------------------------------------------------------------------------------------------------------------ (a) See first column (b) Dr. Kovalchik disclaims beneficial ownership of all shares held as custodian and all shares held by his spouse. Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over) * If the form is filed by more than one reporting person, see Instruction 4(b)(v). SEC 1474 (7-96) FORM 4 (Continued) Table II - Derivative Securities Acquired, Disposed of, or Beneficially owned (e.g., puts, calls, warrants, options, convertible securities) Explanation of Responses: ** Intentional misstatements or /s/ Michael Kovalchik 3/9/1999 omissions of facts constitute ---------------------- -------------- Federal Criminal Violations. **Signature of Date See 18 U.S.C. 1001 and Reporting Person 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 Number. Page 2 SEC 1474 (7-96)
- ----------------------------------------------------------------------------------------------------------------------------------- 1. Title of Derivative 2. Conver- 3. Trans- 4. Trans- 5. Number of 6. Date Exer- 7. Title and Amount of Security (Instr. 3) sion or action action Derivative cisable and Underlying Securities Exercise Date Code Securities Expiration (Instr. 3 and 4) Price of (Month/ (Instr. 8) Acquired (A) Date (Month/ Deriv- Day/ or Disposed Day/Year) ative Year) of (D) (Instr. ---------------------------------------- Security 3, 4 and 5) Date Expira- Amount or -------------------------------- Exer- tion Title Number of Code V (A) (D) cisable Date Shares - ------------------------------------------------------------------------------------------------------------------------------------ Option to Buy Common Stock 16.125 5/12/97 4/22/01 Common 3,750 - ------------------------------------------------------------------------------------------------------------------------------------ 16.125 4/23/98 4/22/01 Common 3,750 - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ----------------------------------------------------------------------------------------------------------------------------------- 1. Title of Derivative 8. Price 9. Number 10. Ownership 11. Nature of Security (Instr. 3) of of Form of Indirect Deriv- Deriv- Derivative Beneficial ative ative Security: Ownership Security Securities Direct (D) (Instr. 4) (Instr. 5) Beneficially or Indirect Owned at (I) End of Month (Instr. 4) (Instr. 4) - ------------------------------------------------------------------------------------------------------------------------------------ Option to buy common stock N/A 3,750 D - ------------------------------------------------------------------------------------------------------------------------------------ N/A 3,750 D - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------