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*
Modahl Mary

(Last) (First) (Middle)
C/O AMERICAN WELL CORPORATION
75 STATE STREET, 26TH FLOOR

(Street)
BOSTON MA 02109

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
09/16/2020
3. Issuer Name and Ticker or Trading Symbol
American Well Corp [ AMWL ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
Director 10% Owner
X Officer (give title below) Other (specify below)
Chief Marketing 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)
Common Stock 220,000 D
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
Stock Options (1) 09/05/2022 Common Stock 263,999 1.77 D
Stock Options (2) 06/12/2024 Common Stock 175,999 1.8 D
Stock Options (3) 04/25/2028 Common Stock 87,999 5.51 D
Stock Options (4) 12/05/2029 Common Stock 219,999 5.8 D
Explanation of Responses:
1. The stock options were granted on September 5, 2012 and are fully vested.
2. The stock options were granted on June 12, 2014 and are fully vested.
3. The stock options were granted on April 25, 2018 and vest over a four-year period, with 25% of the options vesting on the first anniversary of the grant date and the remaining options vesting in equal quarterly installments thereafter.
4. The stock options were granted on December 5, 2019 and vest over a four-year period, with 25% of the options vesting on the first anniversary of the grant date and the remaining options vesting in equal quarterly installments thereafter.
Remarks:
Exhibit 24 - Power of Attorney
/s/ Bradford Gay, as attorney-in-fact for Mary Modahl 09/16/2020
** 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.
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