1. Background of the Insured and Policyholder Name / Company name of the Insured * Address of the Insured * NIT, CC o CE * Policy Number and Item * Certificate No 2. Insured's contact information Name of contact * NIT, CC o CE * Address Telephone Cellular phone * E-mail address * Repeat E-mail * 3. History of the Claim Date of occurrence/Date of knowledge of the event * Time of Incident (if known) Place of loss/location * Facts (detailed description) * Cause (if known) Damages (if known) Claim (estimated value of loss) 4. Claimant (if different from insured contact, broker or agent) Name NIT, CC o CE 5. Consent of the holder of personal data * I authorize EVEREST COMPAÑÍA DE SEGUROS GENERALES COLOMBIA S.A., (hereinafter the Insurer) Nit. 901.839.751-3, with main domicile at Carrera 7 # 71- 52 Torre B ofc. 1001 of Bogotá D.C., as responsible for the treatment of personal and biometric data, so that any information provided may be compiled, stored, consulted, used, processed, shared, recorded, for the purposes of 1). Claim analysis. 2). The settlement and payment of claims; 3) The integral management and payment of the contracted insurance contract(s), including the management that may be eventually required by co- insurers and/or reinsurers and/or adjusters; 4). The preparation of technical-actuarial studies, statistics, surveys, analysis of market trends and, in general, insurance technical studies; 5). Sending information related to financial education, customer satisfaction surveys and other communications inherent to the insurance activity and in connection with my business relationship with the Insurer; 6). Exchange of tax information by virtue of legal provisions or international treaties and agreements signed by Colombia; 7). The prevention and control of money laundering and the financing of terrorism. 8) To the insurance intermediary(ies) designated in the policy(ies); 9). To the co-insurers or reinsurers in Colombia or abroad; 10) To FASECOLDA; 11). To the countries where the databases and/or servers controlled by the Insurer are hosted, for reasons of efficiency in the processing and storage of data. 12) To Everest Group, Ltd., its subsidiaries and affiliates. I declare that I have been informed of 1). The existence of the Processing Policies, which are published in www.everestglobal.com/co-es and can also be requested by phone +576015149240 in Bogota; 2). That data owners are entitled to the rights established in Law 1581 of 2012 and its regulatory Decrees or other rules that modify, add or complement it, especially the rights to: a). Know, update and rectify data b). Request proof of the authorization granted; c). Be informed of the use given to their personal data; d). File complaints before the Superintendence of Industry and Commerce for infringements to the legal provisions in force e). To revoke the authorization and/or request the deletion of the data when the treatment does not respect the principles, rights and constitutional and legal guarantees. f). Access free of charge to your personal data that have been subject to Processing; g). Choose the means by which I wish to be contacted for the purpose of complaint management and modify the times in which I wish to be contacted for the purpose of such management, when I prefer to be contacted at times other than those established by law; 3). That the information I provide about children and adolescents responds to and respects their best interests and fundamental rights; 4). That the answers to the questions I have been asked or will be asked about sensitive personal data are optional. I authorize* Submit