0001104659-18-029977.txt : 20180502 0001104659-18-029977.hdr.sgml : 20180502 20180502211115 ACCESSION NUMBER: 0001104659-18-029977 CONFORMED SUBMISSION TYPE: 3 PUBLIC DOCUMENT COUNT: 2 CONFORMED PERIOD OF REPORT: 20180502 FILED AS OF DATE: 20180502 DATE AS OF CHANGE: 20180502 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Stack Richard S. CENTRAL INDEX KEY: 0001584403 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38468 FILM NUMBER: 18801519 MAIL ADDRESS: STREET 1: 3284 ALPINE ROAD CITY: PORTOLA VALLEY STATE: CA ZIP: 94028 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Starling William N JR CENTRAL INDEX KEY: 0001324130 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38468 FILM NUMBER: 18801518 MAIL ADDRESS: STREET 1: 2300 BUCKSKIN ROAD CITY: POCATELLO STATE: ID ZIP: 83201 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: SYNERGY LIFE SCIENCE PARTNERS L P CENTRAL INDEX KEY: 0001384771 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38468 FILM NUMBER: 18801521 BUSINESS ADDRESS: STREET 1: 3282 ALPINE RD CITY: PORTOLA VALLEY STATE: CA ZIP: 94028 BUSINESS PHONE: 714-815-9099 MAIL ADDRESS: STREET 1: 3282 ALPINE RD CITY: PORTOLA VALLEY STATE: CA ZIP: 94028 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: Synergy Venture Partners, LLC CENTRAL INDEX KEY: 0001584405 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: 3 SEC ACT: 1934 Act SEC FILE NUMBER: 001-38468 FILM NUMBER: 18801520 BUSINESS ADDRESS: STREET 1: 3284 ALPINE ROAD CITY: PORTOLA VALLEY STATE: CA ZIP: 94028 BUSINESS PHONE: (650) 854-9171 MAIL ADDRESS: STREET 1: 3284 ALPINE ROAD CITY: PORTOLA VALLEY STATE: CA ZIP: 94028 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Inspire Medical Systems, Inc. CENTRAL INDEX KEY: 0001609550 STANDARD INDUSTRIAL CLASSIFICATION: SURGICAL & MEDICAL INSTRUMENTS & APPARATUS [3841] IRS NUMBER: 261377674 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 9700 63RD AVENUE N STREET 2: SUITE 200 CITY: MAPLE GROVE STATE: X1 ZIP: 55369 BUSINESS PHONE: 763-205-7970 MAIL ADDRESS: STREET 1: 9700 63RD AVENUE N STREET 2: SUITE 200 CITY: MAPLE GROVE STATE: X1 ZIP: 55369 3 1 a3.xml 3 X0206 3 2018-05-02 0 0001609550 Inspire Medical Systems, Inc. INSP 0001384771 SYNERGY LIFE SCIENCE PARTNERS L P 1350 BAYSHORE HIGHWAY, SUITE 920 BURLINGAME CA 94010 0 0 1 0 0001584405 Synergy Venture Partners, LLC 1350 BAYSHORE HIGHWAY, SUITE 920 BURLINGAME CA 94010 0 0 1 0 0001584403 Stack Richard S. 1350 BAYSHORE HIGHWAY, SUITE 920 BURLINGAME CA 94010 0 0 1 0 0001324130 Starling William N JR 1350 BAYSHORE HIGHWAY, SUITE 920 BURLINGAME CA 94010 0 0 1 0 Series B Convertible Preferred Stock Common Stock 741494 D Series C Convertible Preferred Stock Common Stock 419663 D Series D Convertible Preferred Stock Common Stock 195465 D Series E Convertible Preferred Stock Common Stock 272391 D Series F Convertible Preferred Stock Common Stock 466494 D Shares of Series B, Series C, Series D, Series E and Series F Convertible Preferred Stock (collectively, the "Convertible Preferred Stock") have no expiration date and are convertible, at the option of the holder, into shares of Common Stock at the then-effective conversion rate for no additional consideration (subject to the payment of cash in lieu of any fractional shares in accordance with the Issuer's Sixth Amended and Restated Certificate of Incorporation (as amended, the "Certificate of Incorporation")). The shares of Convertible Preferred Stock will automatically convert into shares of Common Stock at the then-effective conversion rate for no additional consideration (subject to the payment of cash in lieu of any fractional shares in accordance with the Certificate of Incorporation) immediately prior to the closing of the Issuer's initial public offering. Shares of Series B Convertible Preferred Stock are convertible into shares of Common Stock at a 1-for-0.1855 conversion rate. Shares of Series C, Series D and Series F Convertible Preferred Stock are convertible into shares of Common Stock at a 1-for-0.1504 conversion rate. Shares of Series E Convertible Preferred Stock are convertible into shares of Common Stock at a 1-for-0.1728 conversion rate. Synergy Venture Partners, LLC ("SVP LLC") serves as the sole General Partner of Synergy Life Science Partners, LP ("Synergy"). As such, SVP LLC possesses sole voting and investment control over the securities owned by Synergy, and may be deemed to have indirect beneficial ownership of the securities held by Synergy. SVP LLC, however, owns no securities of the Issuer directly. Mudit K. Jain, a director of the Issuer, and each of Messrs. Stack and Starling are Managers of SVP LLC and share voting and dispositive power over the shares held by Synergy. Such persons and entities disclaim beneficial ownership of the shares held by Synergy except to the extent of his or its proportionate pecuniary interest therein. Exhibit List: Exhibit 24 - Power of Attorney /s/ Richard Buchholz, Attorney-in-Fact for Synergy Life Science Partners, LP 2018-05-02 /s/ Richard Buchholz, Attorney-in-Fact for Synergy Venture Partners, LLC 2018-05-02 /s/ Richard Buchholz, Attorney-in-Fact for Richard S. Stack 2018-05-02 /s/ Richard Buchholz, Attorney-in-Fact for William N. Starling, Jr. 2018-05-02 EX-24 2 ex-24.htm EX-24

Exhibit 24

 

POWER OF ATTORNEY

 

Know all by these presents, that the undersigned hereby constitutes and appoints each of Timothy P. Herbert, Richard Buchholz and Steven Jandrich or any of them signing singly, and with full power of substitution, the undersigned’s true and lawful attorney-in-fact to:

 

(1)                       execute for and on behalf of the undersigned, in the undersigned’s capacity as an officer and/or director of Inspire Medical Systems, Inc. (the “Company”), Forms 3, 4, and 5 in accordance with Section 16(a) of the Securities Exchange Act of 1934 and the rules thereunder;

 

(2)                       do and perform any and all acts for and on behalf of the undersigned which may be necessary or desirable to complete and execute any such Form 3, 4, or 5, complete and execute any amendment or amendments thereto, and timely file such form with the SEC and any stock exchange or similar authority; and

 

(3)                       take any other action of any type whatsoever in connection with the foregoing which, in the opinion of such attorney-in-fact, may be of benefit to, in the best interest of, or legally required by, the undersigned, it being understood that the documents executed by such attorney-in-fact on behalf of the undersigned pursuant to this Power of Attorney shall be in such form and shall contain such terms and conditions as such attorney-in-fact may approve in such attorney-in-fact’s discretion.

 

The undersigned hereby grants to each such attorney-in-fact full power and authority to do and perform any and every act and thing whatsoever requisite, necessary, or proper to be done in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as the undersigned might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that such attorney-in-fact, or such attorney-in-fact’s substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers herein granted.  The undersigned acknowledges that the foregoing attorneys-in-fact, in serving in such capacity at the request of the undersigned, are not assuming, nor is the Company assuming, any of the undersigned’s responsibilities to comply with Section 16 of the Securities Exchange Act of 1934.

 

This Power of Attorney shall remain in full force and effect until the undersigned is no longer required to file Forms 3, 4, and 5 with respect to the undersigned’s holdings of and transactions in securities issued by the Company, unless earlier revoked by the undersigned in a signed writing delivered to the foregoing attorneys-in-fact.

 

IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be executed as of this 26th day of April, 2018.

 

 

/s/ William N. Starling, Jr.

 

Synergy Venture Partners, LLC

 

By: William N. Starling, Jr.

 

Title: Managing Director

 

 

 

/s/ William N. Starling, Jr.

 

Synergy Life Science Partners, LP

 

By: William N. Starling, Jr.

 

Title: Managing Director

 

 

 

/s/ William N. Starling, Jr.

 

William N. Starling, Jr.

 

 

 

/s/ Richard S. Stack, M.D.

 

Richard S. Stack, M.D.