Waiver of health insurance scheme for the partner & legal dependents of the Employee

The undersigned:
1. Mr Mitamag-Mi-Bississong Luc Didier, born May 14th 1979, in Douala Cameroon, hereinafter
referred to as "employee",
and
2. Mrs Gwladys Christelle Peg, born June 16th 1985, in Sangmelima Cameroon, hereinafter
referred to as "partner",
and
3. SLK Kribi Towage S.A, established in Doula, Cameroon, legally represented by Mr. Bernard
Grandmont, hereinafter referred to as "employer"
Declare that:
1. the employer has arranged a health insurance scheme with Activia S.A.

2. the employer and the employee have an employment contract.

3. The employer, in accordance with the obligations of the National Collective Agreement on
Seafaring Professions and related Trades of the Republic of Cameroon of March 2010, has
made an offer to the employee to enter himself and his direct dependents (legal wife and
children up to the age of 18) into a health insurance scheme.

4. the employee has received the offer with a description of the contents of the health
insurance scheme.

5. both the employee and the partner have taken note of the offer to enter into a health
insurance scheme and that they are familiar with the content of the health insurance scheme
and the resulting entitlements, rights and related obligations arising from it.

6. the employee and his partner do not wish to accept the offer of the health insurance scheme
for the partner and children (if applicable).

1. By not accepting the offer, the partner and children (if applicable) cannot derive any rights
under the collective health insurance scheme, now or in the future, until this declaration is
revoked.

1. this declaration continues to apply in full in the event of a change in civil status and/or family
situation.

2. the employer, the employee and the partner can only revoke this declaration jointly and in
writing.

3. in the event of revocation of this declaration, entitlement to participate in the health

insurance scheme exists for the period after the revocation of this declaration to the extent
that Activia S.A. accepts the risks.
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 Waiver of health insurance scheme for the partner & legal dependents of the Employee

4. after revocation of this declaration, the employee and the partner have no right to health
insurance entitlements to the extent that they relate to the period before the revocation.

5. the employer will not pay contributions to Activia S.A. for the partner and children (if
applicable).

Agreed and drawn up in triplicate:

Mitamag-Mi-Bississong Luc Didier

Kribi, Cameroon 23/10/2020

(employee’s name and signature) (place) (date)

Gwladys Christelle Peg

Kribi, Cameroon 23/10/2020

(partner’s name and signature) (place) (date)

Mike Fleming

Douala …………………
Contract Manager (date)

The employee and the partner acknowledge that acceptance by ACTIVA S.A. depends on the
health declaration completed by the employee and any subsequent related medical examination.