Republic of the Philippines)

Province of Cagayan ) S.S.

Tuguegarao City )
x------------------------------------------x

AFFIDAVIT OF LOSS

I, JIMMY P. BALIGA, Filipino, of legal age, married and a resident of

Balzain Highway, Tuguegarao City, Cagayan after having been duly sworn to in
accordance with law, do hereby deposes and states, THAT:

1. I am a plan holder of health care insurance with Caritas Health

Shield which became effective on June 29, 2001;

2. As such I was issued the original policy which bears with it the
insurance no. E101-1028705;

3. Said insurance policy was placed along with other important

documents in an envelope and kept the same in a cabinet in my
house;

4. However, just lately, I was in shocked when I checked the cabinet

and found out that the insurance policy was missing;

5. Despite diligent search and efforts to locate the said insurance

policy, I could not find them such that I now believe that they are
now lost beyond recovery;

6. As such, I am executing this affidavit to attest to the veracity and

truthfulness of the foregoing statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day

of February 2017 in Tuguegarao City, Cagayan, Philippines.

JIMMY P. BALIGA
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of February 2017 in

Tuguegarao City, Cagayan, Philippines.

Doc. No._____
Page No. ____
Book No._____
Series of 2017.