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I, __________________
of legal age, Filipino and presently residing at
________________________________________, and for and in consideration of my amount of
____________________________ (P __________). I do hereby forever
QUITCLAIM all my rights, claims or actions of whatever nature against Company Name. as well as
their officers and employees, which we have or may have hereafter, in connection the vehicular
incident that occurred on _____________ at __________.
Place, _________ 20__.
Subscribed and sworn to before me this ____________ day of, _________ 20__.

Signature over printed name

CTC No. _____________________
Issued on ____________________
At __________________________

Doc. No. ________
Page No. ________
Book No. ________
Series of ________