Republic of the Philippines

City of Zamboanga )s.s.

X------------------------------------X

AFFIDAVIT OF LOSS

I, IRINEO M. QUIJANO, of legal age, married, Filipino citizen and a resident of 1

Aquarius Drive, Guiwan, Zamboanga City, Philippines, after having been duly sworn to
in accordance with law, hereby depose and say, that:

1. I applied for an Insurance Coverage and subsequently approved with Pryce

Plans Incorporated and as such I was issued an Insurance Policy bearing
number II-45-00032 and Insurance Certificate;

2. Said Insurance Policy and Certificate were usually kept in our residence for
safekeeping;

3. However, I recently discovered that the Insurance Policy and Certificate were lost
due to inadvertence;

4. I exerted diligent efforts to locate and to look for the above-mentioned Insurance
Policy and Certificate in other places but the same proved futile;

5. For all intents and purposes, I am now declaring the above-mentioned Insurance
Policy and Certificate lost and beyond recovery;

6. I execute this Affidavit to attest to the truth of the foregoing facts based on my
personal knowledge and authentic records for whatever legal purpose it may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand on this 28 th day of

September 2009 at Zamboanga City, Philippines.

IRINEO M. QUIJANO
Affiant

SUBSCRIBED AND SWORN to before me on this 28 th day of September 2009,

at Zamboanga City, Philippines, Affiant exhibited to me his Community Tax Certificate
bearing No. 03020885 issued on 05 January 2009 at Zamboanga City, Philippines.

GIAN PAOLO U. ENRIQUEZ

. . NOTARY PUBLIC
Zamboanga City
Until 31 December 2010
Notarial Commission No. 032-2009
Doc. No. 240 Door 1, 2nd Floor, LDM Bldg.,Pilar St., Zamboanga City
Page No. 48 PTR No. 0013439-01/07/09
Book No. XIV IBP No. 727083-01/07/09
Series of 2009 At Zamboanga City
Roll No. 49871
MCLE Compliance No. II- 0012458-09/09/08