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Form No. 3-- WAIVER Release and Quitclaim Vehicular Accident

(WAIVER Release and Quitclaim Vehicular Accident)

DEED OF RELEASE, WAIVER AND QUITCLAIM

We, the spouses _____________ and _____________, both of legal ages, Filipinos, and residents of _____________, Philippines, hereby DECLARE AND MANIFEST:

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 _____________ of the hospital and medical bills and expenses incurred by the _____________ for injuries sustained, I, WE hereby absolutely release, completely clear, and forever discharge the said _____________ and his driver _____________ from any action, cause of action, sum of money, liability, damages, claims and demands whatsoever, which in law or in equity I/we have, or which I/we, our heirs, insurer, successors and assigns hereafter may have upon or by reason of the injuries sustained by me/us, and the damage sustained by our _____________ motor vehicle with Plate No. ______________ arising from the accident which happened on _____________ at _____________ involving our said _____________ registered in the name of the undersigned _____________ and the _____________ motor vehilce with Plate No. _____________ owned by the said _____________ with the intention to completely and absolutely waive all our right of action, causes of action, claims and demands, of whatever nature, arising from, or in connection with the aforementioned accident.

 

I/We further warrant that I/we will institute no further action against the said _____________ and/or his driver _____________ arising from, by reason of, or in connection with, the aforementioned vehicular accident. I/We also manifest that the said payment / settlement made by the said _____________ shall not be taken by us, our heirs, our insurer or assigns, as a confession and/or admission of liability on the part of the said _____________ or by his driver _____________ in connection with the aforementioned accident.

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

AFFIANT AFFIANT

SIGNED IN THE PRESENCE OF:

__________________ __________________

(ACKNOWLEDGMENT)

 

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