Powszechny Zaklad Ubezpiecze? Spólka Akcyjna : Power of attorney granted by a natural person to participate in the ESM of PZU SA

………………………………………

(place and date)

Power-of-attorney granted by a natural person to participate in the Extraordinary Shareholder Meeting of Powszechny Zakład Ubezpieczeń Spółka Akcyjna convened for 25 March 2022

I, the undersigned ……………...……………………………………………………………………… (first name and surname),

holding …………………………...……………………………………… (specify type and number of the identity document),

residing at ……………………………………………………………………………………… (place of residence and address)

e-mail ……………………………………………………………………………, phone no. ………………………………………

hereby represent that I am a Shareholder of Powszechny Zakład Ubezpieczeń Spółka Akcyjna with its registered

office in Warsaw ("PZU SA"), authorized under …………………………………… (say:

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

and I hereby authorize:

Mr./Ms. ………………………………………………………………………………………………… (first name and surname),

holding …………………………………………………………………… (specify type and number of the identity document)

residing at ……………………………………………………………………………………… (place of residence and address)

e-mail ……………………………………………………………………………, phone no. ………………………………………

or

…………………………………………………………………………………… (business name/name of the entity) with is

registered office in ………………………………

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

(register, entry no.)

e-mail ………………………………………………………………………, phone no. ……………………………………….**

to represent the me at the Extraordinary Shareholder Meeting of PZU SA convened for 25 March 2022, at 11:00 a.m., in the Company's registered office in Warsaw at al. Jana Pawła II 24, 00-133 Warsaw, and in particular to participate and take the floor during the Extraordinary Shareholder Meeting, to sign the attendance list and to vote on my behalf under

……………………… (in words: ……………………………………………………………………………) shares in PZU SA

according to the instructions on how to vote attached to this power-of-attorney/at the proxy's discretion.***

The aforementioned proxy is authorized to represent the Shareholder at the Extraordinary Shareholder Meeting of PZU SA also if the Extraordinary Shareholder Meeting of PZU SA is adjourned.

The proxy is authorized / is not authorized*** to grant further powers-of-attorney.

……………………………………………………

(first name and surname)

• fill out if the power-of-attorney is given to a natural person.
• fill out if the power-of-attorney is given to a person, which is not a natural person.
• delete as applicable.