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Non-Waiver Agreement

Pag - Ibig non - waiver agreement for MRI/SRI claims

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INSURED
LOCATION
PROPERTY INVOLVED CLAIM
DATE OF LOSS

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:
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IT IS HEREBY AGREED by and between the above-named Insured and the Insurance Company or
companies whose names are indicated below that anything done or to be done by said Insurance Company
or Companies, or on their behalf, in connection with the above-described loss, including any investigation
into cause or amount of loss or other matter relative thereto, shall not waive, invalidate, forfeit or modify any
of their rights under the terms and condition of the respective policies issued by them.
This agreement is made for the convenience of the parties hereto, to permit investigation of the
claim and ascertainment of appropriate values of loss or damage to the property involved to be made
without delay and without prejudice to any of their rights.
IN WITNESS WHEREOF, the parties have hereunto set their hands on this ___________day of
____________in _________.
INSURANCE COMPANY

INSURED

By:

By:

_____________________________

________________________________

_______________No. ___________
Date of Issue __________________
Expiry Date ___________________
Place of Issue _________________

_______________No. ___________
Date of Issue _________________
Expiry Date _________________
Place of Issue ________________

SIGNED IN THE PRESENCE OF:

__________________________________

__________________________________

ACKNOWLEDGMENT
REPUBLIC OF THE PHILIPPINES)
City of _______________________) S.S.
BEFORE ME, A Notary Public for and in the City of ________________, this _____ day of
____________, 20____ personally appeared the above-named persons, who have satisfactorily proven to
me their identities through their identifying documents written below their names and signatures, that they
are the same persons who executed and voluntarily signed the foregoing Non-Waiver Agreement, which
they acknowledged before me as their free and voluntary act and deed that Mr./Ms. __________________,
is acting as the representative/Attorney-in-Fact of the INSURANCE COMPANY, and that he/she has the
authority to sign in such capacity.
The foregoing instrument which relates to a Non-Waiver Agreement, consisting of one (1) page
including the page on which this acknowledgment is written, has been signed on the left margin of each and
every page by the parties and the witnesses.
WITNESS MY HAND AND NOTARIAL SEAL on the date and place above written.

NOTARY PUBLIC
Doc. No. _______;
Page No. _______;
Book No. _______;
Series of ________.
 
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