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INSTRUCTIONS : Please complete both sections of this form, have both sections notarized, and return 3 copies with original signatures to: . Claim Form Section: 1.WHAEREAS, certain disputes and financial transactions have occurred between the parties hereto. It is a document agreeing to resolve the parties' differences, dismiss their claims, and release the opposing parties from liability. Use Part I of this Claim Form entitled "CLAIMANT INFORMATION" to identify the beneficial owner(s) of Insulet common stock. Release of All Claims Form One of the documents the insurance adjuster will attempt to get you to sign is the 'Release of All Claims' Form. 19cv08237 (D. N.J.) (the "Action"), you must complete and, on page 6 below, sign this Proof of Claim and Release form ("Claim Form"). 19cv08237 (D. N.J.) (the "Action"), you must complete and, on page 6 below, sign this Proof of Claim and Release form ("Claim Form").