Affidavit of Damage to Warehouse Building by Fire for Fire Insurance Claim)

Republic of the Philippines)

Province of__________________) S.S.
City/Municipality of____________)
x-------------x

AFFIDAVIT

I,____________,of legal age, Filipino,(single / married / widow),and a resident of____________,

Philippines, after being sworn in accordance with law, depose and state:

That I am the__position_of__name of company__, a domestic corporation engaged in the

distribution of a variety of commercial products;

That the said company maintains a warehouse for its products at_____________, Philippines;

That sometime on_____________at around______o'clock in the(morning/afternoon/night), a big

fire broke out in the said warehouse which caused damage on its_____________,and destroyed
its____________and destroyed / damaged / spoiled many of the assorted stocks and merchandise
stored in the said warehouse;

That the said fire was controlled and put off only about_____hours later by the efforts of the
different fire brigades which responded to our call for assistance;

That I am executing this Affidavit to attest to the truth of the foregoing and in support of the
company's claim on the fire / building insurance of the said warehouse / building.

IN WITNESS WHEREOF,I have hereunto set my hand this____________at the City

of____________, Philippines.

Affiant

(JURAT)