Republic of the Philippines)

Iloilo City )S.S

x------------------------------x

AFFIDAVIT OF LOSS

I, ____________________, of legal age, married, Filipino citizen and

a resident of _________________________, Philippines, under oath, depose and
say that:

That I am a bona fide plan holder of St. Peter Life Plan, Iloilo City with
_____________________ with effectivity date June 19, 2019;

That sometime in January 2020, I discovered said Original LPA Policy was
lost or misplaced among my voluminous file at my house and despite diligent
efforts to locate the same could not be found and believed lost already;

I am executing this Affidavit of Loss to attest to the truth of the foregoing

and in support of my request/application for the replacement of the said St.
Peter Life Plan Policy.

IN WITNESS WHEREOF, I have hereunto set my hand this 8 th day of

September 2020 at Iloilo City, Philippines.

_______________________
Affiant

SUBSCRIBED AND SWORN to before me this 8th day of September

2020 at Iloilo City, Philippines, affiant exhibiting to me his ____________ as his
competent evidence of identity.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2020