QUITCLAIM

I, __________________________, in my own accord and will, will not avail of the company’s
HMO policy. As such, the benefits and conditions that are available in the aforementioned HMO
policy cannot be availed by me or any of my beneficiaries.

In line with my decision to not avail of the company’s HMO policy, I have understood that I have
waived my right to claim any damages from the Company for any work-related injuries or sickness
such as but not limited to the following:

1. Injury or illness caused by fortuitous events, as defined by law;1

2. Injury or illness caused by a fellow employee, whether intentional or due to negligence;
3. Charges for injury or illness not covered or those that exceed SSS and PhilHealth benefits;

SIGNED:

______________________________ ______________________________________
Employee’s Name and Signature Human Resources and Administration Manager

1Fortuitous events by definition are extraordinary events not foreseeable or avoidable. It is

therefore, not enough that the event should not have been foreseen or anticipated, as is
commonly believed but it must be one impossible to foresee or to avoid. The mere difficulty
to foresee the happening is not impossibility to foresee the same. (Sicam, et al. v. Jorge, et
al., G.R. No. 159617, August 8, 2007)