Republic of the Philippines)

Province of ______________) s.s.

City of _________________ )

SWORN DECLARATION OF NO PREVIOUS MINOR/MAJOR

CHECK UP/CONSULTATION and CONFINEMENT
I, _______________________, of legal age, Filipino citizen, married, and a
resident of __________________________________, Philippines, after having been duly
sworn to in accordance with law, do hereby depose and say:

1. That I am a lawful holder of an Insurance Policy with Policy No.

________________, issued in my favor by PRU LIFE U.K.;

2. That I intend to file an insurance claim with the above-stated Insurance

Company, particularly the Accelerated Life Care Benefit;

3. That among the requirements for the said claim is a Certified Copy of all
Minor or Major Check-up/Consultation, Confinement Records and Laboratory
Results before October ___, 20__;

4. That I do hereby declare that neither was there any minor/major check-
up/consultation conducted on me, nor have I been hospitalized/confined before
October ___, 20__, hence, I have no copy of the above-required records and
laboratory results;

5. That I am executing this affidavit to attest to the veracity of the foregoing,

particularly to prove that neither was there any minor/major check-
up/consultation conducted on me, nor have I been hospitalized/confined before
October ___, 20__, and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_____________ at _________________________, Philippines.

____________________________
Affiant
ID No. _______________________

SUBSCRIBED AND SWORN TO before me this _____________ at

______________________________, Philippines, affiant exhibiting to me his valid and
competent proof of his identity indicated below his name

Doc. No.
Page No.
Book No.
Series of 2020