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  • WAIVER Release and Quitclaim Vehicular Accident

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    279 views2 pages

    WAIVER Release and Quitclaim Vehicular Accident

    Uploaded by

    Richard

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    of 2

    RELEASE, WAIVER AND QUITCLAIM

    KNOW ALL MEN BY THESE PRESENTS:

    I, _____________________, of legal age, single/married, Filipino citizen and resident of


    ________________________________________________, ____________ Philippines, hereby
    DECLARE AND MANIFEST:

    1) That for and in consideration of the amount of _____________ (P_____________) in


    cash, in hand received by us to our full and complete satisfaction, and the payment
    and settlement by (name of person paying bills) of the hospital and medical bills and
    expenses incurred by me for injuries sustained as a result of my own negligence, I
    hereby absolutely release, completely clear, and forever discharge the said (name of
    registered owner) and his driver (__________________) from any action, cause of
    action, sum of money, liability both criminal and civil, damages, claims and demands
    whatsoever, which in law or in equity I have, or which I, my heirs, insurer, successors
    and assigns hereafter may have upon or by reason of the injuries sustained by me on
    (date of accident) and the damage sustained by my _____________ motor vehicle
    with Plate No. ______________, with the intention to completely and absolutely
    waive all my right of action, causes of action, claims and demands, of whatever
    nature, arising from, or in connection with the aforementioned accident.

    2) I further warrant that I will institute no further action against the said (name of
    registered owner) and/or his driver(_____________) arising from, by reason of, or in
    connection with, the aforementioned vehicular accident.
    3) I also manifest that the said payment / settlement made by the said
    (Mr.___________________) shall not be taken by me, my spouse (if married), my
    heirs, my insurer or assigns, as a confession and/or admission of liability on the part
    of the said (Mr._________________) or by his driver (______________) in
    connection with the aforementioned accident.

    IN WITNESS WHEREOF, we have hereunto set our hands this _____________ at


    _____________, Philippines.

    AFFIANT

    SUBSCRIBED AND SWORN TO before me this ________________________ at


    ___________________________. Affiant exhibiting to me his/her valid government I.D. No.
    ____________________ issued on________________ in the City of ________________.

    Notary Public

    Doc. No. ___;


    Page No. ___;
    Book No. ___;
    Series of 2016.

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