Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-2439

2. Registrant Information.

Registrant Reference Number: 1-33133775

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.

28-MAR-13

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

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. Unknown

Product Name: Precor

• Active Ingredient(s)
  • (S)-METHOPRENE
    • Unknown

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Res. - In Home / Rés. - à l'int. maison

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

Product applied, apartment treated by PCO

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: Female

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Irritated skin

• Gastrointestinal System
  • Symptom - Nausea
  • Symptom - Vomiting

• Nervous and Muscular Systems
  • Symptom - Headache

• Liver
  • Symptom - Pain

• Reproductive System
  • Symptom - Other
  • Specify - Ovaries hurt

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Contact with treated area

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.

Unknown

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.)

In November 2012 caller became symptomatic after apartment was treated. Caller did seek medical attention multiple times prior to reporting the incident.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

Since the re-entry time frame is unknown, unable to determine whether sufficient time had passed before re-entry. Caller advised symptoms would not be anticipated following exposure to this active ingredient or finished product and suggested other causes may be affecting the callers health.