Exhibit 10.58(c)

Schedule A

Notice of Restricted Stock Grant

 

Participant:    [•] Company:    WellPoint, Inc. Notice:    You have been granted
the following award of restricted shares of common stock of the Company in
accordance with the terms of the Plan and the attached Restricted Stock Award
Agreement. Plan:    WellPoint 2006 Incentive Compensation Plan Grant:    Grant
Date: [•]    Number of Shares of Restricted Stock: [•] Period of Restriction:   
The Period of Restriction applicable to the number of Shares of your Restricted
Stock listed in the “Shares” column below shall commence on the Grant Date and
shall lapse on the date listed in the “Lapse Date” column below.

 

Shares

  

Lapse Date

 

 

 

   However, in the event that a Change of Control occurs before your
Termination, the Period of Restriction shall immediately lapse. In addition, if
you participate in the WellPoint, Inc. Executive Severance Plan, the lapsing of
the Period of Restriction upon, or in connection with, a “change of control” (as
defined in the Severance Plan) will be determined in accordance with Sections
4.1 and 4.3 of the Severance Plan. Rejection:    If you do not want to accept
your Restricted Stock, please return this Agreement, executed by you on the last
page of this Agreement, at any time within sixty (60) days after the Grant Date
to WellPoint, Inc., 120 Monument Circle, Indianapolis, Indiana 46204, Attention:
Stock Administration. Do not return a signed copy of this Agreement if you
accept your Restricted Stock. If you do not return a signed copy of this
Agreement within sixty (60) days after the Grant Date, you will have accepted
your Restricted Stock and agreed to the terms and conditions set forth in this
Agreement and the terms and conditions of the Plan.

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Restricted Stock Award Agreement

This Restricted Stock Award Agreement (this “Agreement”) dated as of the Grant
Date (the “Grant Date”) set forth in the Notice of Restricted Stock Grant
attached as Schedule A hereto (the “Grant Notice”) is made between WellPoint,
Inc. (the “Company”) and the Participant set forth in the Grant Notice. The
Grant Notice is included in and made part of this Agreement.

1. Period of Restriction. The Period of Restriction with respect to the
Restricted Stock shall be as set forth in the Grant Notice (the “Period of
Restriction”). The Participant acknowledges that prior to the expiration of the
applicable portion of the Period of Restriction, the Restricted Stock may not be
sold, transferred, pledged, assigned, encumbered, alienated, hypothecated or
otherwise disposed of (whether voluntary or involuntary or by operation of law
by judgment, levy, attachment, garnishment or any other legal or equitable
proceedings (including bankruptcy)). Upon the expiration of the applicable
portion of the Period of Restriction, the restrictions set forth in this
Agreement with respect to the Restricted Stock theretofore subject to such
expired Period of Restriction shall lapse, except as may be provided in
accordance with Section 9 hereof.

2. Ownership. The Participant agrees that the Participant’s ownership of the
Restricted Stock will be evidenced solely by a “book entry” (i.e., a
computerized or manual entry) in the records of the Company or its designated
stock transfer agent in the Participant’s name. Upon expiration of the
applicable portion of the Period of Restriction, the Company shall transfer the
vested shares to the Participant’s account with the Company’s captive broker.

3. Termination.

(a) Retirement. If the Participant’s Termination is due to Retirement (for
purposes of this Agreement, defined as the Participant’s Termination after
attaining age fifty-five (55) with at least ten (10) completed years of service,
the restrictions upon the Restricted Stock shall continue to lapse throughout
the Period of Restriction except on those shares required to meet the minimum
income tax liability; provided, however, that if the Participant’s Termination
due to Retirement is during the calendar year of the Grant Date, the Restricted
Stock shall be forfeited on a pro-rata basis, measured by the number of months
in that calendar year during which the Participant was employed by the Company
or an Affiliate (e.g., if the Participant’s Retirement occurs in September, 25%
(or 3/12) of the Restricted Stock will be forfeited), and the Period of
Restriction on the non-forfeited portion of the Restricted Stock shall continue
to lapse throughout the Period of Restriction except on those shares required to
meet the minimum income tax liability.

(b) Death and Disability. If the Participant’s Termination is due to death or
Disability (for purposes of this Agreement, as defined in the applicable
WellPoint Long-Term Disability Plan), then the Period of Restriction shall
immediately lapse, causing any restrictions which would otherwise remain on the
Restricted Stock to immediately lapse.

(c) Other Terminations. If the Participant’s Termination is by the Company or an
Affiliate or by the Participant for any reason other than death, Disability or
Retirement, then all Restricted Stock for which the Period of Restriction had
not lapsed prior to the date of such Termination shall be immediately forfeited.

(d) Clawback Provision. If the Participant is an Executive (as defined by
WellPoint) at the time of the Participant’s Termination, the Restricted Stock
shall be forfeited if the Participant breaches any provision of Section 3.6 or
3.10 of the WellPoint, Inc. Executive Severance Plan (the “Severance Plan”),
regardless of whether the Participant is then a participant in the Severance
Plan, in which case the Participant shall be subject to the “Return of
Consideration” provision contained in Section 3.7 of the Severance Plan.

4. Transferability of the Restricted Stock. The Participant shall have the right
to appoint any individual or legal entity in writing, on a Designation of
Beneficiary form as his/her beneficiary to receive any Restricted Stock (to the
extent not previously terminated or forfeited) under this Agreement upon the
Participant’s death. Such designation under this Agreement may be revoked by the
Participant at any time and a new beneficiary may be appointed by the
Participant by execution and submission to the Company, or its designee, of a
revised Designation of Beneficiary form to this Agreement. In order to be
effective, a designation of beneficiary must be

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completed by the Participant on the Designation of Beneficiary form and received
by the Company, or its designee, prior to the date of the Participant’s death.
If the Participant dies without such designation, the Restricted Stock will
become part of the Participant’s estate.

5. Taxes and Withholdings. Upon the expiration of the applicable portion of the
Period of Restriction or such earlier dates as the Participant elects pursuant
to Section 83(b) of the Code, or as of which the value of any Shares of
Restricted Stock first becomes includible in the Participant’s gross income for
income tax purposes, the Participant shall notify the Company if the Participant
wishes to pay the Company in cash, check or with shares of WellPoint common
stock already owned for the satisfaction of any taxes of any kind required by
law to be withheld with respect to such Shares; provided, however, that pursuant
to any procedures, and subject to any limitations as the Compensation Committee
of the Board of Directors of the Company (“Committee”) may prescribe and subject
to applicable law, if the Participant does not notify the Company in writing at
least 14 days prior to the applicable lapse of the Period of Restriction, then
the Participant will satisfy such withholding obligations by withholding Shares
otherwise deliverable to the Participant pursuant to the Restricted Stock
(provided, however, that the amount of any Shares so withheld shall not exceed
the amount necessary to satisfy required Federal, state, local and non-United
States withholding obligations using the minimum statutory withholding rates for
Federal, state, local and/or non-U.S. tax purposes, including payroll taxes,
that are applicable to supplemental taxable income). Any such election made by
the Participant must be irrevocable, made in writing, signed by the Participant,
and shall be subject to any restrictions or limitations that the Committee, in
its sole discretion, deems appropriate. In the event that the Participant elects
immediate Federal income taxation with respect to all or any portion of this
award of Restricted Stock pursuant to Section 83(b) of the Code, the Participant
agrees to deliver a copy of such election to the Company within ten (10) days
after filing such election with the Internal Revenue Service.

6. Rights as a Shareholder. The Participant shall have all rights of a
shareholder (including, without limitation, dividend and voting rights) with
respect to the Restricted Stock, for record dates occurring on or after the
Grant Date and prior to the date any such Shares of Restricted Stock are
forfeited in accordance with this Agreement, except that any dividends or
distributions paid in Shares or other securities (including, without limitation,
any change in the shares of Restricted Stock pursuant to Section 4.3 of the
Plan) with respect to the Restricted Stock shall, during the Period of
Restriction, be deposited with the Company or any holder appointed pursuant to
Section 2 hereof, together with a stock power endorsed in blank or other
appropriate instrument of transfer, or credited to the Participant’s book-entry
account established under Section 2 hereof, as applicable, and shall be subject
to the same restrictions (including, without limitation, the Period of
Restriction) as such Restricted Stock and otherwise considered to be such
Restricted Stock for all purposes hereunder.

7. No Right to Continued Employment. Neither the Restricted Stock nor any terms
contained in this Agreement shall confer upon the Participant any express or
implied right to be retained in the employment or service of the Company or any
Affiliate for any period, nor restrict in any way the right of the Company,
which right is hereby expressly reserved, to terminate the Participant’s
employment or service at any time for any reason. The Participant acknowledges
and agrees that any right to have restrictions on the Restricted Stock lapse is
earned only by continuing as an employee of the Company or an Affiliate at the
will of the Company or such Affiliate, or satisfaction of any other applicable
terms and conditions contained in the Plan and this Agreement, and not through
the act of being hired, being granted the Restricted Stock or acquiring Shares
hereunder.

8. The Plan. This Agreement is subject to all the terms, provisions and
conditions of the Plan, which are incorporated herein by reference, and to such
regulations as may from time to time be adopted by the Committee. In the event
of any conflict between the provisions of the Plan and this Agreement, the
provisions of the Plan shall control, and this Agreement shall be deemed to be
modified accordingly. The Plan and the prospectus describing the Plan can be
found on the Company’s HR intranet. A paper copy of the Plan and the prospectus
shall be provided to the Participant upon the Participant’s written request to
the Company at WellPoint, Inc., 120 Monument Circle, Indianapolis, Indiana
46204, Attention: Corporate Secretary, Shareholder Services Department.

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9. Compliance with Laws and Regulations.

(a) The Restricted Stock and the obligation of the Company to sell and deliver
Shares hereunder shall be subject in all respects to (i) all applicable Federal
and state laws, rules and regulations and (ii) any registration, qualification,
approvals or other requirements imposed by any government or regulatory agency
or body which the Committee shall, in its discretion, determine to be necessary
or applicable. Moreover, the Company shall not deliver any certificates for
Shares to the Participant or any other person pursuant to this Agreement if
doing so would be contrary to applicable law. If at any time the Company
determines, in its discretion, that the listing, registration or qualification
of Shares upon any national securities exchange or under any state or Federal
law, or the consent or approval of any governmental regulatory body, is
necessary or desirable, the Company shall not be required to deliver any
certificates for Shares to the Participant or any other person pursuant to this
Agreement unless and until such listing, registration, qualification, consent or
approval has been effected or obtained, or otherwise provided for, free of any
conditions not acceptable to the Company.

(b) The Shares received upon the expiration of the applicable portion of the
Period of Restriction shall have been registered under the Securities Act of
1933 (“Securities Act”). If the Participant is an “affiliate” of the Company, as
that term is defined in Rule 144 under the Securities Act (“Rule 144”), the
Participant may not sell the Shares received except in compliance with Rule 144.
Certificates representing Shares issued to an “affiliate” of the Company may
bear a legend setting forth such restrictions on the disposition or transfer of
the Shares as the Company deems appropriate to comply with Federal and state
securities laws.

(c) If, at any time, the Shares are not registered under the Securities Act,
and/or there is no current prospectus in effect under the Securities Act with
respect to the Shares, the Participant shall execute, prior to the delivery of
any Shares to the Participant by the Company pursuant to this Agreement, an
agreement (in such form as the Company may specify) in which the Participant
represents and warrants that the Participant is purchasing or acquiring the
shares acquired under this Agreement for the Participant’s own account, for
investment only and not with a view to the resale or distribution thereof, and
represents and agrees that any subsequent offer for sale or distribution of any
kind of such Shares shall be made only pursuant to either (i) a registration
statement on an appropriate form under the Securities Act, which registration
statement has become effective and is current with regard to the Shares being
offered or sold, or (ii) a specific exemption from the registration requirements
of the Securities Act, but in claiming such exemption the Participant shall,
prior to any offer for sale of such Shares, obtain a prior favorable written
opinion, in form and substance satisfactory to the Company, from counsel for or
approved by the Company, as to the applicability of such exemption thereto.

10. Notices. All notices by the Participant or the Participant’s assignees shall
be addressed to WellPoint, Inc., 120 Monument Circle, Indianapolis, Indiana
46204, Attention: Stock Administration, or such other address as the Company may
from time to time specify. All notices to the Participant shall be addressed to
the Participant at the Participant’s address in the Company’s records.

11. Other Plans. The Participant acknowledges that any income derived from the
Restricted Stock shall not affect the Participant’s participation in, or
benefits under, any other benefit plan or other contract or arrangement
maintained by the Company or any Affiliate.

 

WELLPOINT, INC. By:  

 

Printed:   William J. Ryan Its:   Chairman, Compensation Committee   WellPoint,
Inc. Board of Directors

I DO NOT accept this Restricted Stock:

 

Signature:  

 

      Printed Name:  

 

    Date: