REPUBLIC OF THE PHILIPPINES )

PROVINCE OF _______________ ) s.s

WAIVER OF RIGHTS TO CLAIM

We, __________________________, of legal age, Filipino and a resident of

_________________, ________________________, ________________________, of legal age,
Filipino and a resident of _______________________, and _____________________, of legal
age, Filipino, and a resident 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

________________________;

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
________________________;

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

_____________________________ at _________________________________.

_________________ _____________________
Affiant Affiant
Id:______________________ Id:________________________

___________________________
Affiant
Id: ___________________________

ACKNOWLEDGMENT

BEFORE ME, this _________________________, a Notary Public in the Province of

___________________, Philippines, personally appeared the following persons with their valid
identification card, known to me 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.

Witness My Hand and Notarial Seal on.

NOTARY PUBLIC

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2023.