AFFIDAVIT OF LOSS

REPUBLIC OF THE PHILIPPINES

CITY OF MAKATI
I, <<AFFIANTS FULL NAME>>, of legal age, <<Marital Status>>,
<<Nationality>>, and residing at <<Full Mailing Address>>, after being duly sworn
in accordance with the law, depose and say:
1. That I am currently an owner/ enrolled/bearer of an insurance policy described
as follows:
a.
b.
c.
d.

POLICY NAME :
SUBSCRIBER NAME :
ISSUING COMPANY :
POLICY COVERAGE & SUBJECT :

2. That on <<Date of occurrence>> the above said document/policy was

<<Provide the reason for such loss>> and is now considered lost.
3. That after exercising countless measures and effort to recover it, the said
document remains lost and is now beyond recovery.
4. That I am executing this affidavit for the purpose of <<Indicate Purpose of
Affidavit>>.

IN WITNESS WHEREOF, I have hereunto set my hand this <<Date>> day of

<<Month>>, 2008, in the city of Makati, Philippines.

_________________________
<<
FULL NAME >>
AFFIANT

ACKNOWLEDGMENT
Republic of the Philippines]
______________________ ] S.S.
BEFORE ME, a Notary Public in and for Makati City, this ___ day of ______________, 2008,
personally appeared:
Name
CTC/TIN No.
Issued on/at
known to me to be the same person who executed the foregoing affidavit and acknowledged to me
that the same is his true and voluntary act and deed.
IN WITNESS WHEREOF, I have set my hand and seal on the day, year and place first written.
Notary Public
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