REPUBLIC OF THE PHILIPPINES)

IN THE CITY OF _______________)S.S.

SWORN CERTIFICATION AND UNDERTAKING

I, __________Hector P. Villamero__________, under oath, depose and state that:

1. I am the claimant/insured under Commonwealth Insurance Company Policy No.
______CV1534123_________ in connection with the vehicular incident that happened last
______July_10,_2023________at___Brgy. Tikay, City of Malolos, Bulacan______ of which my
insured vehicle and/or its passenger/s incurred damages in the estimated amount of Php
_____________;
2. I hereby state under oath that I have not made any arrangement with the owner or
driver of the other vehicle/s involved in the said incident for the settlement of the damage/s
caused to my vehicle or its passenger/s, and; that I have not received any amount of money or
whatever consideration from the other party or its insurer in payment of the damage/s except, for
“Policy Deductible” and “Assured Share for Betterment” as owner’s participation to my
claim of insurance coverage with Commonwealth Insurance Company nor have I signed any
acknowledgment receipt or quitclaim, waiver and release in favor of the other party or its insurer;
3. I hereby undertake not to sign, execute or deliver any acknowledgment receipt,
quitclaim, waiver and release in favor of the other party or its insurer prior to and at the time of
the filing of my claim for insurance coverage with Commonwealth Insurance Company in
connection with the said vehicular incident as aforestated;
4. I understand that in the event I shall thereafter be found to have received any
amount of money or whatever consideration aside from “Policy Deductible” and “Assured
Share for Betterment” from the other party or its insurer for the settlement of my claim in
connection with the said vehicular incident, or that I signed any acknowledgment receipt and/or
quitclaim, waiver and release in favor of the other party or its insurer, the same shall be a cause
for the denial of my claim for insurance coverage with Commonwealth Insurance Company, and
that I be liable for Perjury or misrepresentation for signing this Sworn Certification and
Undertaking;
IN WITNESS WHEREOF, I have hereunto set my hand this ______ day of
_____________________ at Makati City, Philippines.

_____Hector P.
Villamero_____
Insured/Claimant/Driver

Valid ID No. ___N02 - 89 - 104810____

SUBSCRIBED AND SWORN to before me this ____day of _____________, _________

at Makati City, Philippines.

Doc. No. ____;

Page No. ____;
Book No.____;
Series of 2022.