For Non-Life Insurance Claims

(Material Damage - All Risk)

NON-WAIVER AGREEMENT

Insured :
Location :
Property Involved Claim :
Date of Loss :

IT IS HEREBY AGREED by and between the above-named Insured and the Insurance Company or
companies whose names are indicated below that anything done or to be done by said Insurance Company
or Companies, or on their behalf, in connection with the above-described loss, including any investigation into
cause or amount of loss or other matter relative thereto, shall not waive, invalidate, forfeit or modify any of
their rights under the terms and condition of the respective policies issued by them.

This agreement is made for the convenience of the parties hereto, to permit investigation of the claim
and ascertainment of appropriate values of loss or damage to the property involved to be made without delay
and without prejudice to any of their rights.

IN WITNESS WHEREOF, the parties have hereunto set their hands on this ___________day of
____________in _________.

INSURANCE COMPANY INSURED

By: By:
______________________________
Policy Number: ___________________ ________________________________
Date Issue: ____________________ ID:_______________No. __________
Expiry Date: ______________________ Date of Issue _________________
Place of Issue: _________________ Expiry Date _________________
Place of Issue ________________

SIGNED IN THE PRESENCE OF:

__________________________________ __________________________________

ACKNOWLEDGMENT

REPUBLIC OF THE PHILIPPINES) City

of _______________________) S.S.

BEFORE ME, A Notary Public for and in the ________________________, province of

___________________, this _____ day of ____________, 20____ personally appeared the above-named
persons, who have satisfactorily proven to me their identity through their identifying documents written below
their names and signatures, that they are the same persons who executed and voluntarily signed the
foregoing instrument, which they acknowledged before me as their free and voluntary act and deed.

The foregoing instrument which related to a Non-Waiver Agreement, consisting of one (1) page
including this Acknowledgment which has been signed on the left margin of each and every page by the
parties and the witnesses.

WITNESS MY HAND AND NOTARIAL SEAL on the date and place above written.

NOTARY PUBLIC
Doc. No. _______;
Page No. _______;
Book No. _______;
Series of ________.