Republic of the Philippines)

City of Pasig )
x---------------------x

AFFIDAVIT OF LOSS

I,VILMA NACION MACAIRAN, Filipino, of legal age, married, and a

resident of 243 East Kamias S, Santa Cruz, Antipolo City, Philippines, after
being duly sworn to in accordance with law, hereby depose and state:

That I am a grantee of a Health Maintenance Organization (HMO) which is

Intellicare with membership card no: 1195000003321971;I

That on October 22, 2018 at around_11:00 o’clock in the morning, while I

was at the Antipolo Public Market, I lost my wallet which I usually place in
my back pocket;

That inside the said wallet are several cards which includes my membership
card of Intellicare;

That despite diligent search and efforts to locate the said wallet I could not
find them such that I now believe that they are now lost beyond recovery

As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing and to support my application for the issuance of another
membership card of Intellicare in lieu of the one that was lost.

IN WITNESS WHEREOF, I have hereunto set my han

d this November 06, 2018 at Pasig City, Philippines.

VILMA NACION MACAIRAN

SUBSCRIBED AND SWORN to before me this ____________________, affiant

exhibited to me her Competent Evidence of Identity by way of
__________________ issued at ______________ on __________________.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of ______.