Powszechny Zaklad Ubezpiecze? Spólka Akcyjna : Notification by a natural person about granting a power-of-attorney in electronic form

…………………………………………

(place and date)

Management Board

of Powszechny Zakład Ubezpieczeń Spółka Akcyjna

Rondo Ignacego Daszyńskiego 4

00-843 Warsaw

Notice of a natural person

on granting an authorisation, in an electronic form, to attend the Extraordinary Shareholder Meeting of

Powszechny Zakład Ubezpieczeń Spółka Akcyjna to be held on 13 September 2023

The Shareholder providing the notice of granting an authorisation in an electronic form

…………………………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………………

(give the precise identification and contact of the Shareholder: first name and surname, place of residence and address, type and number of ID document, PESEL, telephone number, e-mail address)

authorisedonthebasisof…………………………*

(say:…………………………….……………………………………………………)

shares of Powszechny Zakład Ubezpieczeń Spółka Akcyjna, as recorded in the securities account kept

by

…………………………………………………………………………………………………………………………………………

(give the name of an institution keeping the securities account)

I hereby inform you that on ........................................ an authorisation in an electronic form was granted to

…………………………………………………………………………………………………………………………………………

(give the precise identification and contact of the Proxy: first name and surname/business name, place of residence and address/registered office and address, type and number of ID document/register and number in the register, PESEL/NIP (VAT No.), telephone number, e-mail address)

• to represent me as the shareholder and owner of the aforementioned shares of Powszechny Zakład Ubezpieczeń Spółka Akcyjna at the Extraordinary Shareholder Meeting 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 exercising voting rights on my behalf at the Extraordinary Shareholder Meeting on the basis of those shares.

I hereby supplement the notice with documents in the form of a PDF file: the authorisation and documents that necessary identification documents for the Proxy and the Shareholder.

……………………………………………………

(signature of the Shareholder)

• If the Shareholder has any shares recorded in the securities account, give the name of an institution keeping the account. If the Shareholder has any shares recorded in more than one securities account and appoints separate Proxies to exercise the rights in relation to shares recorded in each of those accounts, give the number of shares in the specific securities account.