Date:

(On Company’s Letter Head)

Insurance Broker Appointment Letter

I the undersigned:

Your Company Name

Registered and licensed by the Department of Economic Development – Commercial

License Number: (if a company)

Do hereby appoint: Capital Shield Insurance Brokers Services LLC (CSIB), an

insurance brokerage company, registered and licensed by:

1- Department of Economic Development - Commercial License Number: 1160464

2- Insurance Authority - Registration number: 236
3- Health Authority- Abu Dhabi - Authorization Certificate Number: B045

to be our exclusive insurance broker and risk consultant for all of our lines of
business.

By this we authorize CSIB to use our name and to represent us in the most appropriate
and efficient manner, approaching the insurance providers/companies to secure our
best interests and insurance coverage needs and managing our insurance portfolio
including but not limited to: placing our new insurance covers, implementing
necessary changes on the existing ones, renewing our expired policies, collecting -
delivering and receiving any documents and following up on our claims.

We authorize our current insurer(s) to provide CSIB with any and all information they
request regarding our insurance and claims history in respect to all classes of
insurance.

This appointment letter revokes any other appointment letter issued from our end to
any other party and shall take immediate effect from this date.

Any assistance required by the relevant parties is highly appreciated.

Name:
Designation:
Stamp & Signature: