86 APPENDIX III: ........................................................ PATIENT INSURANCE AND INDEMNITY 87 CT TG01 -01 Version v10.0 27 June 2018 Confidential 6 / 87 MEDICAL EMERGENCY CONTACT DETAILS: Principal Investigator(s): [Name(s) and 24 hour contact number(s)] Trial Physician Notification of serious adverse events SAE Tel/Fax line : Contact at your stu dy centre : 1. [Name(s) and 24 hour contact number(s)] Contact at your study centre: 2 [Name(s) and 24 hour contact number(s)] CT TG01 -01 Version v10.0 27 June 2018 Confidential 7 / 87 Sponsor Signature Page Trial number: CT TG01 -01 Trial Title: A Phase I/II Trial of TG01 and Gemcitabine as Adjuvant Thera py for Tr eating Patients with Resecte d Adenocarcinoma of the Pancreas Clinical Trial Sponsor : Signature: Date: Responsible Trial Physician: Signature: Date: CT TG01 -01 Version v10.0 27 June 2018 Confidential 8 / 87 Investigator Signatu re Page Trial number: CT TG01 -01 Trial Title: A Phase I/II Trial of TG01 and Gemcitabine as Adjuvant Therapy for Treating Patients with Resected Ade nocarcinoma of the Pancreas Trial centre: I agree to conduct this trial in accordance with the protocol including any trial protocol amendments and in compliance with Good Clinical Practice and applicable regulatory requirements. Signature: ..............................………...……...