RELEASE OF CLAIM AND SUBROGATION AGREEMENT

FOR THE SOLE CONSIDERATION OF TWENTY-EIGHT THOUSAND (28,000) the receipt whereof
is hereby acknowledged, I/We HEGEN LIBRANDO ABAO for myself/ourselves, my/our heirs'
representatives, successors, and assigns, do hereby release and forever discharge
COMMONWEALTH INSURANCE COMPANY, INC. of and all actions, claims, demands and rights
of action whatsoever, that now exists or may hereafter develop and particularly on account of all
known, unknown and unanticipated injuries, damages and losses arising out of and as a
consequence of an accident that occurred on or about November 25, 2023.

I/We further agree that this RELEASE may be pleaded in bar to any suit, or proceedings
which I/we or anyone in my/our behalf, may have taken or may be taken in connection with the
accident hereinbefore mentioned, that this payment or service is not an admission of liability and is
voluntarily accepted as a full and final compromise adjustment and settlement of all claims, and
that the payment of said amounts shall never be construed as an admission of liability by the party
or parties hereby released.

I/We manifest that the terms of this RELEASE and SUBROGATION RECEIPT have been read or
explained to me in English/Tagalog which I/we know and are thoroughly understood by /us.

IN WITNESS of which, I/we have affixed my/our signature/s below this __________ at
__________________________.

___________________________________
(Signature & Name in Print)

SIGNED IN THE PRESENCE OF:

__________________________________ ___________________________________

ACKNOWLEDGEMENT

REPUBLIC OF THE PHILIPPINES ) S.S.

)
BEFORE ME, a Notary Public in and for _______, personally appeared
_____________________ with Community Tax Certificate No. ____________________issued
on______________________at ___________________, known to me and known to be the same
person who executed the foregoing instrument and acknowledged before me that the same is their
free and voluntary act and deed.

WITNESS MY HAND AND SEAL this _____ day of __________, 202__.

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