Powszechny Zaklad Ubezpiecze? Spólka Akcyjna : Authorisation granted on behalf of a legal person or a business unit not being a legal person, but having legal capacity

………………………………………

(place and date)

Authorisation granted on behalf of a legal person

or a business unit not being a legal person, but having legal capacity on the basis of the Act

to attend the Extraordinary Shareholder Meeting of Powszechny Zakład Ubezpieczeń Spółka Akcyjna to be held on 13 September 2023

I/we, the undersigned, ……………………………………………………………………………………………… (first name

and surname),

…………………………………………………………………………… (type and name of an ID document),

residing in ………………………………………………………………………………………………………… (place of

residence and address),

e-mail address ……………………………………………………………………, telephone number

………………………………………

…………………………………………………………………………… (type and name of an ID document),

residing in ………………………………………………………………………………………………………… (place of

residence and address),

e-mail	address	……………………………………………………………………,	telephone	number
………………………………………,
authorised to act on behalf of			(name of the Shareholder)
with	its	registered	office	in	……………………………………,	(address)

……………………………………………………………………………,

entered in the ………………………………………………………………………… (register, number in the register),

hereby represent that …………………………………………………………………………………… (name of the

Shareholder)

with its registered office in ……………………………………………… is the Shareholder of Powszechny Zakład

Ubezpieczeń Spółka Akcyjna with its registered office in Warsaw ("PZU SA"), authorised on the basis of

…………………………………………………………(say:

……………………………………………………………………………………………) shares of PZU SA ("Shareholder")

and I/we hereby authorise:

Mr/Mrs ……………………………………………………………………………………………………………………… (first

name and surname),

…………………………………………………………………………… (type and name of an ID document),

residing in ……………………………………………………………………………………………………… (place of residence

and address),

e-mail address ……………………………………………………………………, telephone number

………………………………………*

or

…………………………………………………………………… (name of an entity) with its registered office in

………………………………

(address) ……………...........................…………………………………..……………………………………………, entered in

the ………………………………………………………………………… (register, number in the register)

e-mail address ……………………………………………………………………, telephone number

………………………………………**

to represent the Shareholder at the Extraordinary Shareholder Meeting of PZU SA to be held on 13 September 2023 at 12:00 in the registered office of the Company at Rondo Ignacego Daszyńskiego 4, 00-832 Warsaw, including, in particular, attending and speaking at the Extraordinary Shareholder Meeting, signing the list of attendance and voting

on my behalf on the basis of ……………………… (say:

……………………………………………………………………………) shares of PZU SA in accordance with the instruction

on a method of voting, as attached hereto / at the Proxy's own discretion.***

The Proxy is also authorised to represent the Shareholder at the Extraordinary Shareholder Meeting of PZU SA when the debate is resumed after an adjournment of the Extraordinary Shareholder Meeting of PZU SA.

The Proxy is authorised / is not authorised*** to grant further authorisations.

……………………………………………………

(signature)

• fill in if the authorisation is granted to a natural person.
• fill in if the authorisation is granted to a person not being a natural person.
• delete if not applicable.