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*
Eichhorn Gary

(Last) (First) (Middle)
C/O INSULET CORPORATION
9 OAK PARK DRIVE

(Street)
BEDFORD MA 01730

(City) (State) (Zip)
2. Date of Event Requiring Statement (Month/Day/Year)
05/14/2007
3. Issuer Name and Ticker or Trading Symbol
INSULET CORP [ PODD ]
4. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
X Director 10% Owner
Officer (give title below) Other (specify below)
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 40,038 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 Option (Right to Buy) (1) 03/09/2014 Common Stock 3,573 $2.5 D
Stock Option (Right to Buy) (2) 12/09/2015 Common Stock 7,138 $4.86 D
Explanation of Responses:
1. This option may be exercised at any time, whether vested or not, but, upon termination of service as a director or consultant, we may repurchase any unvested shares at the exercise price paid for the shares. This option vests in equal monthly installments each month for 36 months starting on July 22, 2004, subject to continued service as a director or consultant.
2. This option may be exercised at any time, whether vested or not, but, upon termination of service as a director or consultant, we may repurchase any unvested shares at the exercise price paid for the shares. This option is subject to a three-year vesting period, with 50% of the total award vesting one year after the grant date, 25% of the total award vesting two years after the grant date and 25% of the total award vesting three years after the grant date, subject to continued service as a director or consultant.
Remarks:
Exhibit 24 ? Power of Attorney
/s/ R. Anthony Diehl, attorney in fact 05/14/2007
** 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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