Attached to and forming MAPFRE INSULAR INSURANCE CORPORATION.

Policy No. : 1002201007503

Claim No. : 100221000002639
File No. / Type : 1 / ODP
Assured : ELIZALDE, MARIA NOEMI ALFONSO

RELEASE OF CLAIM AND LOSS SUBROGATION RECEIPT

FOR THE SOLE CONSIDERATION OF PESOS SIXTY-FOUR THOUSAND FOUR HUNDRED EIGHTY-SIX PESOS ONLY (Php
64,486.00) , the receipt thereof is hereby acknowledged:

I/We ELIZALDE, MARIA NOEMI ALFONSO for myself/ourselves, my/our heirs, representatives, successors, and assigns do
hereby release and forever discharge MAPFRE INSULAR INSURANCE CORPORATION of and from all actions, claims and demands
whatsoever that now exist or may hereafter develop and particularly on account of all known and unanticipated injuries and damages
arising out of or in consequence of a vehicular incident which occured on October 19,2022 at LUCENA CITY.

I/We hereby agree that said MAPFRE INSULAR INSURANCE CORPORATION is subrogated to all my/our rights of recovery of
all claims, demands, and right of actions on account of loss, or injuries as a consequence of the above mentioned accident. That I/We
hereby promise my/our fullest cooperation and assistance to said MAPFRE INSULAR INSURANCE CORPORATION for the recovery
whether in court or otherwise, of payment hereby made and that refusal on my/our part to render such cooperation and assistance as
may be reasonable required in the successful handling of the recovery will create an obligation on my/our part to return the full amount
paid to me/us including accidental expenses incurred.

I/We furthermore agree that the foregoing sum is voluntarily accepted as full and final compromise, adjustment and settlement of
all claims, that the payment of said amount shall never be construed as an admission of liability by the party or parties hereby released.

IN WITNESS WHEREOF , I/We have set my/our hands this ______________________

PLEASE READ CAREFULLY BEFORE SIGNING

ELIZALDE, MARIA NOEMI ALFONSO

Assured/Assignee

Witness Witness

REPUBLIC OF THE PHILIPPINES) S. S.

___________________________ )

Before me this _____ day of ______________ in the City of _______________ Affiant having exhibited and submitted a
photocopy of his/her/their _______________ with number ______________ issued by _______________ issued on ______________,
with expiration date on foregoing Release of Claim and Loss Subrogation Receipt, and acknowledge the same to be his/her/their free
act and deed and I certify that before execution thereof, the said agreement was read over and fully explained to the same person by
me, and that he/she/they declared before execution thereof that he/she/they understood the same.

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