REPUBLIC OF THE PHILIPPINES)

CAGAYAN DE ORO CITY ) S.S

AFFIDAVIT OF LOSS

I, XXX, of legal age, Filipino, married, and a resident of XXXXX, PHILIPPINES, after having
been duly sworn to according to law, hereby depose and state:

1. That I am a Member of the XXXX;

2. That as such I was issued an Insurance Policy;
3. That I misplaced the said policy inadvertently;
4. That I have made a diligent search and inquiry to locate and retrieve the document
but to no avail. It is irretrievably lost and cannot be recovered;
5. That I am executing this Affidavit of Loss to attest to the truth of the foregoing facts
and for whatever legal purpose it may serve;

IN WITNESS WHEREOF, I have hereunto set my hand this XXX XXXX XXXXX at the
XXXXXXXX

XXXX
Affiant
Tin No: XXXXXX

SUBSCRIBED AND SWORN to before me this XXXXXX at the XXXX. Affiant exhibited to me
his valid proof of identification as described above.