RELEASE OF CLAIM AND SUBROGATION RECEIPT

FOR THE SOLE CONSIDERATION OF

PESOS: & 00/100 ( )
Receipt where of is hereby acknowledge, I / We the undersigned
for myself / ourselves, my/ our heirs, representative, Successors and
assignee, do hereby release and forever discharge___COMMONWEALTH INSURANCE
COMPANY of and from all action, claims, demand and rights of action. Under Policy No.
covering my motor vehicle which is more particularly described as a
with Plate No. , Serial No.
insured under the said policy on account of vehicular accident involving the above-mentioned which
occurred on
I / We agree that this release may be placed in by any suit or proceeding which I / We or
anyone in my/our behalf,any have taken or maybe taken in connection with the above mentioned
vehicular accident and that is payment or service is voluntarily accepted representing full and
final settlement, adjustment of all claims and the payment of said amount shall never be
construed as an admission of liability by the party or parties hereby release.

I /We that the time of accident / loss, the above mentioned vehicle belonged exclusively to
me/us and no other person or persons has any interest therein and that there was no encumbrance
of any kind of whatever on said property. The said accident / loss did not originate by any act,
design or procurement or in consequence of any fraud or evil practice done or suffered by or on
the part of the deponent’s privity or consent to violate the condition of the said policy or render
it void; and that no articles mentioned herein by such were lost, damaged or destroyed and
belonging to and the possessions of the said loss; that no property saved has been in any manner
concealed, and that no attempt to deceive the said_________________________ as to the extent
of the said loss or otherwise has any manner been made.

I /We further agree that the said___COMMONWEALTH INSURANCE COMPANY is

subrogated to all my / our rights of recovery of all claims, demands and rights of action on
account of loss, or injury as a consequence of the above mentioned accident from any person,
persons corporation or whomsoever maybe liable thereof; that I / We hereby promise my / our
fullest cooperation and assistance to said___COMMONWEALTH INSURANCE COMPANY
for the recovery whether in court or otherwise, of the payment hereby mde that the refusal on
my / our part to tender such corporation and assistance as maybe reasonably required in the
successful handling of the recovery will create an obligation on my / our part to return to the full
amount paid to me / us including all incidental expenses incurred.

I / We further agree and authorized___COMMONWEALTH INSURANCE COMPANY

to begin suit, prosecute, compromise or withdraw either in my / our name or in their name, all
legal proceedings which they may deem necessary to enforce my / our claim or claims.

I/ We manifest that the terms and condition of this instrument have been read and
thoroughly understood.

In WITNESS WHEREOF, I / We have set my / our hand/s and seal this_________________

day of _______________.

PLEASE READ CAREFULLY BEFORE SIGNING

ASSURED / ASSIGNEE

_______________________________________
WITNESS