SEC Form 3
FORM 3 UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549

INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES

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*
Dombro Lisa

(Last) (First) (Middle)
C/O AGILON HEALTH, INC.
1 WORLD TRADE CENTER, SUITE 2000

(Street)
LONG BEACH CA 90831

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
04/14/2021
3. Issuer Name and Ticker or Trading Symbol
agilon health, inc. [ AGL ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
Exper. & Innovation Officer
5. If Amendment, Date of Original Filed (Month/Day/Year)
6. Individual or Joint/Group Filing (Check Applicable Line)
X Form filed by One Reporting Person
Form filed by More than One Reporting Person
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)
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: Direct (D) or Indirect (I) (Instr. 5) 6. Nature of Indirect Beneficial Ownership (Instr. 5)
Date Exercisable Expiration Date Title Amount or Number of Shares
Options (Rights to Buy) (1) 04/27/2027 Common Stock 500,000 $1 D
Options (Rights to Buy) (2) 04/27/2027 Common Stock 750,000 $3 D
Options (Rights to Buy) (3) 01/24/2028 Common Stock 250,000 $1 D
Options (Rights to Buy) (4) 07/29/2030 Common Stock 200,000 $4.5 D
Explanation of Responses:
1. These options were granted on April 27, 2017, and fully vested on March 1, 2021.
2. These options were granted on April 27, 2017, and will vest on the date CD&R Vector Holdings, L.P. achieves a return of at least three times its initial investment in agilon health, inc., subject to continued employment.
3. These options were granted on January 24, 2018, and are scheduled to vest in four equal installments on each anniversary of the grant date, subject to continued employment.
4. These options were granted on July 29, 2020, and are scheduled to vest in four equal installments on each anniversary of the grant date, subject to continued employment.
Remarks:
Exhibit List: Ex.24 - Power of Attorney
/s/ Lyn Amor Macaraeg, as Attorney-in-Fact 04/14/2021
** Signature of Reporting Person Date
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).
** 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.
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 Number.