REPUBLIC OF THE PHILIPPINES)

CITY OF ____________________ ) S.S.

WAIVER OF RIGHTS TO CLAIM

I, MICHELLE A. ASUNCION, Filipino, of legal age, with residence and postal address at 2-G 1st
West Crame, San Juan City, Metro Manila, after having been duly sworn in accordance with law, hereby
depose and state:
1. That I am the biological and natural mother of ALYSSA MARIELLE A. LOPEZ.
2. That ALYSSA MARIELLE A. LOPEZ passed away on the 5th of September, 2019, at
the City of Manila.
3. That at the time of her death, ALYSSA MARIELLE A. LOPEZ held the position of
Customer Service Associate of VXI with address at 11th Floor 5-Ecom Center, Pacific
Drive, Mall of Asia Complex, Pasay City. She had an insurance with Generali Life
Assurance Philippines Inc. as part of her employment benefits. I am a beneficiary of
the same.
4. That I hereby freely and voluntarily waive my rights and interests to the proceeds and
any other benefits derived or arising from the insurance plan with Generali Life
Assurance Philippines Inc. with insurance claim estimated at Php ______________,
in favor of ANTONIO ALAN O. LOPEZ, the biological and natural father of ALYSSA
MARIELLE A. LOPEZ.
5. That I will hold Generali Life Assurance Philippines Inc. free and harmless from
any claim, action, damage or liability that may arise out of the release of said proceeds.
6. That I am executing this Affidavit in order to attest to the truthfulness of the foregoing
and for all legal intents and purposes.

IN WITNESS WHEREOF, I have affixed my signature this ___th day of _______________,

2020.

MICHELLE A. ASUNCION
Affiant
SIGNED IN THE PRESENCE OF

__________________________ _________________________

SUBSCRIBED AND SWORN TO BEFORE ME this ___th day of _______________, 2020, by

affiant exhibiting to me her Valid Government Issued Identification Document (ID) with the following
details: ___________________ No. _______________, issued on _______________ at ______________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2020.
aaol/waiverofrightsduck/06282020/1P-S