Attached to and forming OONA INSULAR INSURANCE CORPORATION

Policy No. : 1001992007357

Claim No. : 100231000003081
File No. / Type : 1 / ODP
Assured : VILLAMERO, HECTOR P.

RELEASE OF CLAIM AND LOSS SUBROGATION RECEIPT

FOR THE SOLE CONSIDERATION OF PESOS THIRTEEN THOUSAND ONE HUNDRED NINETY-SEVEN PESOS AND NINETY-
EIGHT CENTAVOS ONLY (Php 13,197.98) , the receipt thereof is hereby acknowledged:

I/We VILLAMERO, HECTOR P. for myself/ourselves, my/our heirs, representatives, successors, and assigns do hereby release and forever
discharge OONA INSULAR INSURANCE CORPORATION of and from all actions, claims and demands whatsoever that now exist or may
hereafter develop and particularly on account of all known and unanticipated injuries and damages arising out of or in consequence of a vehicular
incident which occured on December 20,2023 at IN FRONT OF ROBINSON'S PLACE MALOLOS.

I/We hereby agree that said OONA INSULAR INSURANCE CORPORATION is subrogated to all my/our rights of recovery of all claims,
demands, and right of actions on account of loss, or injuries as a consequence of the above mentioned accident. That I/We hereby promise my/our
fullest cooperation and assistance to said OONA INSULAR INSURANCE CORPORATION for the recovery whether in court or otherwise, of
payment hereby made and that refusal on my/our part to render such cooperation and assistance as may be reasonable required in the successful
handling of the recovery will create an obligation on my/our part to return the full amount paid to me/us including accidental expenses incurred.

I/We furthermore agree that the foregoing sum is voluntarily accepted as full and final compromise, adjustment and settlement of all claims,
that the payment of said amount shall never be construed as an admission of liability by the party or parties hereby released.

IN WITNESS WHEREOF , I/We have set my/our hands this

PLEASE READ CAREFULLY BEFORE SIGNING

VILLAMERO, HECTOR P.
Assured/Assignee

Witness Witness

REPUBLIC OF THE PHILIPPINES) S. S.

)

Before me this day of in the City of Affiant having exhibited and submitted a
photocopy of his/her/their with number issued by issued on , with expiration date on
foregoing Release of Claim and Loss Subrogation Receipt, and acknowledge the same to be his/her/their free act and deed and I certify that before
execution thereof, the said agreement was read over and fully explained to the same person by me, and that he/she/they declared before execution
thereof that he/she/they understood the same.

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