REPUBLIC OF THE PHILIPPINES )

CITY OF ) S.S.

WAIVER OF RIGHTS TO CLAIM

This WAIVER OF RIGHTS TO CLAIM (hereinafter referred to as “WAIVER”), made

and entered into by and between:

1. (insert name/s here)

2. (insert name/s here)
3. (insert name/s here)
4. As follows

All of legal age, Filipino citizens and residents of

______________________________, after having been duly sworn to in accordance with law,
depose and state:

That we are the surviving legitimate heirs/ beneficiaries of the deceased-insured insert
name of deceased-insured ;

That for reasons of gratuity and generosity, we hereby waive all our rights and interest to
claim the insurance benefits on the life of the aforementioned deceased-insured, in favor of
insert name here ;

That we execute this waiver, freely and voluntarily to attest to the foregoing facts and
statements and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, we have herewith affixed our signatures this __ day of

__________, 2016, at ____________________.

Name of Affiant Signature Gov’t ID No. Issued At Issued on

 ACKNOWLEDGEMENT

BEFORE ME this __ day of __________ 20__, at __________, Philippines, personally

appeared the following persons, who are identified by me through competent evidence of
identity:

Name of Affiant Signature Gov’t ID No. Issued At Issued on

Known to me and to me made known to be the same persons who executed the foregoing
instrument and acknowledged to me that the same is their free and voluntary act and deed. This
instrument consisting of __ page/s, including the page on which this acknowledgement is
written, has been signed on each and every page thereof by the concerned parties and their
witnesses.

WITNESS MY HAND AND SEAL, on the date and place first above written.

Doc. No. : _____;

Page No. : _____;
Book No. : _____;
Series of 2016.