NOVEMBER 24, 2008 CIRCULAR NO. 24/08 TO MEMBERS OF THE ASSOCIATION Dear Member: PRE-EMPLOYMENT MEDICAL EXAMINATION PROGRAM (PEME): AMENDMENT TO CLUB PEME FORMS TO INCLUDE MEDICAL HISTORY QUESTIONNAIRE The American Club is introducing an amendment to the pre-employment medical examination (PEME) program policy to further ensure that Members are made aware of pre-existing medical conditions affecting seafarers prior to employment. With effect from February 20, 2009, the American Club will require the attached medical history questionnaire to be completed by the seafarer as part of the Club-approved medical form. The new questionnaire will be integrated into the Club approved medical forms that can be found on the American Club website under Loss Prevention at www.american-club.com . The new policy will apply to Members employing seafarers originating from India, Indonesia, Latvia, Philippines, Poland, Romania, Russia, and Ukraine. The primary purpose of the medical history questionnaire is to: (a) protect the interests of Members by reason of seafarers being compelled to provide a full account of their medical history at the time of the PEME; and (b) prevent against spurious illness claims through a signed declaration of their knowledge of any prior or current condition that may not necessarily be detected during the PEME, but at some later date. For further information, please refer to the American Club website at www.american-club.com or contact Dr. William Moore, Senior Vice President of Risk Control for the Shipowners Claims Bureau, Inc. at Tel: +1 212 847 4542, Fax: +1 212 847 4596 or william.moore@americanclub.com. Yours faithfully, Joseph E. M. Hughes, Chairman & CEO Shipowners Claims Bureau, Inc., Managers for THE AMERICAN CLUB ANNEX AMERICAN CLUB MEDICAL HISTORY QUESTIONNAIRE NAME __________________________________ PHONE _______________________________ ADDRESS _____________________________________________________________________ BIRTHDATE ____/____/____ EMPLOYER ____________________________________________ JOB TITLE _____________________________ SEAMAN CERTIFICATE NO.________________ VESSEL NAME__________________________________________________________________ IN CASE OF EMERGENCY, NOTIFY: ________________________ PHONE ________________ RELATIONSHIP _________________________________________________________________ PERSONAL PHYSICIAN OR CLINIC ________________________________________________ ADDRESS: ____________________________________________________________________ ______________________________________________________________________________ ALLERGIES: ___________________________________________________________________ FAMILY HISTORY Has anyone in your family ever had (check box if yes): Diabetes High Blood Pressure Heart Disease Cancer Mental Illness Epilepsy/Seizure Any other major conditions? _______________________________________________________ ______________________________________________________________________________ If you answered “Yes” to any of the above, please explain: _______________________________ ______________________________________________________________________________ Check the box if you have had or received medical treatment for: Diabetes Yes High Blood Pressure Yes Heart Trouble Yes Rheumatic Fever Yes Hernia Yes Frequent Headaches Yes Cancer/Tumor Yes Dizziness Yes Chronic Cough Yes Shortness of Breath Yes Chest Pain Yes Varicose Veins Yes Arthritis/Gout Yes Asthma Yes Kidney Trouble Yes Tubercul