REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ZAMBOANGA DEL SUR)

CITY OF PAGADIAN ) SS.
AFFIDAVIT OF INSURANCE CLAIM
(COMELEC INSURANCE BENEFIT)

I, __________________, hereby depose and state:

1. THAT I am a Licensed Professional Teacher registered with the
Professional Regulation Commission in Pagadian City,
Zamboanga del Sur, with registration number 0891737, of which,
part my duties and responsibilities is to be a part of the Board of
Election Inspectors (BEI) during regular and special elections;

2. THAT on the said Baranggay and Sangguniang Kabataan Elections, I was

harassed and threatened by some election watcher of being filed
with several administrative and criminal cases for conducting the
counting of ballots not favorable to the watcher’s political party or
political sponsor;

3. THAT the harassment and threats caused me to be extremely stressed out

and profusely worried with which I experience a sleepless night
worrying about the open threats and thus caused my blood pleasure
to shoot up and experience high blood pressure and later on
experience stroke;

4. THAT because of my confinement at the Pagadian City Medical Center, I

incurred a medical bill in the amount of A copy of
my medical bill and official receipt is attached herein and marked as
Annexes “B” and “C”;

5. THAT were it not for the threats and harassment hurled against me by the
political party watchers during the 2023 Baranggay ans
Sangguniang Kabataan Elections last October 30, 2023, I would not have
suffered this too much stress, high blood pressure and stroke, and incur
this hefty hospital bill;

6. THAT this Affidavit of Insurance Claim is being made as a requirement

for my medical reimbursement/insurance benefit offered by the
Commission on Elections for the benefit of the members of
the BEI who served during Elections;

7. I am executing this Affidavit to attest to the truth of the foregoing and for
whatever legal purpose it may serve.

Affiant says nothing further.