REPUBLIC OF THE PHILIPPINES )

CITY OF __________________ ) S.s.

AFFIDAVIT OF UNDERTAKING

I,____________________ , of legal age, Filipino citizen, and a resident of

_________________________________, under oath, hereby depose and state that:

On ___________________, I mistakenly paid the amount of _________ to Kaiser

Policy No ___________________.

The said amount was actually intended for my Kaiser account with Policy Number
___________________ but through my own mistake and oversight, it was credited to
Kaiser Policy No ___________________.

Realizing my mistake, I requested INTERNATIONAL MARKETING GROUP (IMG)

INSURANCE BROKERS CORP. to transfer the amount of ________ from Kaiser Policy No
___________________ to Kaiser Policy No ___________________ and which request
has been granted on the condition that should another member claim the said amount
and present documents proving ownership thereof, I HEREBY UNDERTAKE TO
REIMBURSE INTERNATIONAL MARKETING GROUP (IMG) INSURANCE BROKERS CORP.
the said amount it has transferred to to me;

I furthermore UNDERTAKE TO PROTECT AND SAVE HARMLESS said

INTERNATIONAL MARKETING GROUP (IMG) INSURANCE BROKERS CORP., its directors,
officers and employees from any and all damages, injuries, costs, losses or claims that it
may incur or suffer by reason of its having transferred to me the said amount of
_________ to Kaiser Policy No __________________ which turns out to be owned by
another member;

IN WITNESS WHEREOF, I hereby affix my signature this ____ day of _____, 2023
in the City of _______________, Philippines.

_______________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of _______ 2023, affiant
exhibited to me her _____.

NOTARY PUBLIC

Doc. No. _____

Page No. _____
Book No. _____
Series of 2023