Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-3664

2. Registrant Information.

Registrant Reference Number: 080116436204

Registrant Name (Full Legal Name no abbreviations): WELLMARK INTERNATIONAL

Address: 100 STONE ROAD WEST, SUITE 111

City: GUELPH

Prov / State: ON

Country: CANADA

Postal Code: N1G 5L3

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

23-JUL-08

5. Location of incident.

Country: UNITED STATES

Prov / State: MICHIGAN

6. Date incident was first observed.

Unknown

Product Description

7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.

Active(s)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 2724-352

Product Name: Zoecon Precor IGR Concentrate

• Active Ingredient(s)
  • (S)-METHOPRENE
    • Guarantee/concentration 1.2 %

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Unknown / Inconnu

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Caller is a professional Pest Control Officer and has been working the product since 1980.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Seizure
  • Symptom - Fainting
  • Specify - Blackouts

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

Yes

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Occupational

8. How did exposure occur? (Select all that apply)

Application

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

The caller's symptoms began over 2 years ago. The caller developed blackouts and seizures. The seizures resolved some time ago (caller is on anti-seizure medication) and caller has been working longer hours and experiencing blackouts for past 2-3 weeks. Caller has seen an MD and had blood tests to check his therapeutic blood level which was within normal limits.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

Symptoms described are not expected with product use. The caller was advised to get information about non-company products and continue to work with his MD to determine the reason for his seizures.