| 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, Section 17(a) of the Public Utility Holding Company Act of 1935 or Section 30(h) of the Investment Company Act of 1940 | | OMB APPROVAL | | OMB Number: | 3235-0104 | | Expires: | February 28, 2011 | | Estimated average burden | | hours per response | 0.5 |
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1. Name and Address of Reporting Person*
| C/O INSULET CORPORATION, 9 OAK PARK DRIVE | |
(Street)
| 2. Date of Event Requiring Statement (Month/Day/Year)
08/17/2009 | 3. Issuer Name and Ticker or Trading Symbol
INSULET CORP
[PODD]
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4. Relationship of Reporting Person(s) to Issuer
(Check all applicable) | Director | | 10% Owner | | X | Officer (give title below) | | Other (specify below) | | Chief Commercial Officer |
| 5. If Amendment, Date of Original Filed (Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
| X | Form filed by One Reporting Person | | Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Beneficially Owned |
|---|
| 1. Title of Security (Instr.
4)
| 2.
Amount of Securities Owned (Instr.
4)
| 3. Ownership Form: Direct (D) or Indirect (I) (Instr.
5)
| 4. Nature of Indirect Beneficial Ownership (Instr.
5)
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|---|
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No Securities Are Beneficially Owned
|
0
|
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 Excercise 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 |
|---|
| Explanation of Responses: |
| /s/ R. Anthony Diehl, attorney in fact | 08/18/2009 |
| ** 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. |
POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, that the undersigned hereby
constitutes and appoints Brian Roberts, R. Anthony Diehl and Allison
Dorval, and any one of them acting singly, the true and lawful
attorneys-in-fact and agents, with full power of substitution and
resubstitution, for the undersigned and in the undersigned's name,
place and stead, in any and all capacities (until revoked in writing)
to execute for and on behalf of the undersigned, in any and all of
the undersigned's capacities, any and all statements on Forms 3, 4
and 5 with respect to the undersigned's holdings of and transactions
in securities issued by Insulet Corporation (the ?Company?) in
accordance with Sections 16(a) of the Securities Exchange Act of 1934,
as amended (the ?Exchange Act?), and any and all regulations
promulgated thereunder, and to file the same, with all exhibits
thereto, and any other documents in connection therewith, with the
Securities and Exchange Commission, and with any other entity when
and if such is mandated by the Exchange Act or by the By-laws of the
National Association of Securities Dealers, granting unto said
attorneys-in-fact and agents full power and authority to do and
perform each and every act and thing requisite and necessary fully
to all intents and purposes as the undersigned might or could do in
person thereby ratifying and confirming all that said attorneys-in-
fact and agents, or their substitute or substitutes, may lawfully
do or cause to be done by virtue hereof.
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, this Power of Attorney has been signed
as of August 17, 2009.
Signature: /s/ Peter Devlin
Name: Peter Devlin