NON-WAIVER AGREEMENT

KNOW ALL MEN BY THESE PRESENTS:

INSURED :___________________________________________________
LOCATION :___________________________________________________
DATE OF LOSS :___________________________________________________
PROPERTY INVOLVED :___________________________________________________

DESCRIBED UNDER THE FOLLOWING POLICY (IES):

POLICY INSURANCE COMPANY AMOUNT

IT IS HEREBY MUTUALLY UNDERSTOOD AND AGREED BY and between the above named insured and the
Insurance Company (ies) represented by DFM INSURANCE ADJUSTMENT COMPANY, INC. that nay
action/thing done/taken or to be done by said company (ies) or on their behalf in connection with the above-
described loss including any investigation into cause/origin, claim amount/value or other matter relative thereto shall
not waive, invalidate, forfeit or modify any of their rights under the terms and conditions of the policy (ies).

This agreement is made for the aid and convenience of the parties hereto to permit investigation of the cause/cause
origin of the claim or determination of the value of the said property and the amount of the loss/damage thereto
without delay and prejudice to any of their rights and not be construed as an admission of liability on the part of said
insurance company (ies).

WITNESSED OUR HANDS, THIS __________ day of ____________________ 20__________________in the

__________________________________________________________________________________Philippines.

INSURED:

For the Insurance Company (ies)

DFM INSURANCE ADJUSTMENT COMPANY INC.

By: By:

____________________________________________ ___________________________________________

SIGNED IN THE PRESENCE OF:

____________________________________________ ___________________________________________

REPUBLIC OF THE PHILIPPINES)

_____________________________) S.S

SUBSCRIBED AND SWORN TO before me this ___________day of__________________,20________________

Affiant/s exhibiting their Residence Certificate Nos. dates and places of issue:

Name Residence Cert. No. Date of Issue Place of Issue

_________________________
Notary Public

PTR No. :_______________

Date Issued :_______________
Place Issued:_______________
Doc No.________________;
Page No._______________;
Book No._______________;
Series off _______________