Powszechny Zaklad Ubezpiecze? Spólka Akcyjna : Authorisation granted by a natural person

………………………………………

(place and date)

Authorisation granted by a natural person

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

I, 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

………………………………………

hereby represent that I am 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 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 me 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.***

• 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.

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.

……………………………………………………

(first name and surname)