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CLAIM FORM Provident Fund for Filipino seafarers on NIS-vessels RETURN THE FORM TO: Store brand Life Insurance Ltd. International Operations P.O. Box 1380 Via N-0114 Oslo Norway SURNAME Date of birth
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Filed in Norway Date Filed on Airship (date of departure from home port) PERSUADE FURTHER By forwarding the attached form to: Provident Fund Ltd. E-Mail: PERSUADE THE APPLICANT By forwarding this form to: Provident Fund Ltd. E-Mail: Filed with the Board of Directors of Provident Fund International Operations P.O. Box 1380 Via N-0114 Oslo Norway In accordance with the provisions of Article 2 of the Law No. 2879, dated 6 November 2001, I hereby grant a non-exclusive, worldwide, non-transferable license to use the name 'Provident Fund International Services' without restrictions and without payment of any fees to the party applying for its use, subject to the following: 2. All persons and business entities that hold the right to any of the original rights acquired by the above-named company shall have the legal right, and shall be free to apply for, and receive, the same. All persons and business entities that hold the rights granted above shall have all applicable rights provided for in the Laws of Norway as it may arise from any other law or judicial decision of the International Office. The exclusive use of the names 'Provident Fund International Services' or 'International Services Provident Fund International Services' and the names of the above-named Company shall be deemed to be authorized by the above Company. I hereby authorize the use and publication of the foregoing name (and the name 'International Services Provider' and the names of the above-named companies) under the same conditions and conditions as are provided for the use and publication in Norwegian of the respective names and trademark of the above-named Company. 3. All persons, corporations, partnerships, and associations, with the following exception, will require prior permission from the Board of Directors of the specified Company before the use of the above name and trademark within their respective jurisdiction: (a) in the state of Israel a limited liability company that does not hold a valid license for the use of the above name of the company; and (b) in the state of Georgia a limited liability company that does not hold a valid license for the use of the above name. 4.


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