Powszechny Zaklad Ubezpiecze? Spólka Akcyjna : Notification by a natural person about granting a power of attorney in electronic form to participate in the ESM of PZU SA

……………………………………………

(place and date)

Management Board

of Powszechny Zakład Ubezpieczeń Spółka Akcyjna

Al. Jana Pawła II 24

00-133 Warsaw

Notification by a natural person

about granting a power-of-attorney in electronic form to participate in the Extraordinary Shareholder

Meeting of Powszechny Zakład Ubezpieczeń Spółka Akcyjna convened for 25 March 2022

Shareholder notifying about granting a power-of-attorney in the electronic form

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

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

(insert Shareholder's details and contact information: first name and surname, place of residence and address, type and number of identity document, PESEL, phone no., e-mail address),

authorized under …………………………* (say: ………………………………………………………………………………)

shares of Powszechny Zakład Ubezpieczeń Spółka Akcyjna deposited on a securities account kept

by

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

(insert the name of the institution keeping the securities account)

I hereby advise that on ……………………………………………… a power-of-attorney was granted in the electronic form

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

(insert the Proxy's details and contact information: first name and surname/business name, place of residence and address/registered office and address, type and number of identity document/register and entry number in the register, PESEL/NIP, phone no., e-mail address)

• to represent me as a shareholder and owner of the aforementioned shares of Powszechny Zakład Ubezpieczeń Spółka Akcyjna at the Extraordinary Shareholder Meeting convened for 25 March 2022, at 11 a.m., in the Company's registered office at al. Jana Pawła II 24, 00-133 Warsaw, and in particular to participate and exercise voting rights attached to the aforementioned shares on my behalf at the Extraordinary Shareholder Meeting.

• attach to the notification the following documents in a .pdf file: granted power-of-attorney and documents which should be submitted in order to identify the Proxy and the Shareholder.

……………………………………………………

(Shareholder's signature)

• If a Shareholder holds shares deposited in a securities account, such shareholder should also state the name of the institution keeping the account. If a Shareholder holds shares deposited in more than one securities account and appoints separate Proxies to exercise the rights attached to the shares deposited in each such account, then the number of shares deposited in the given securities account should be stated.