Republic of the Philippines )

Municipality of Palo ) s.s.

Province of Leyte )

AFFIDAVIT OF LOSS

We, NANCY BERGADO FLORES, MARIA ELENA BERGADO HERMOSO and

DANNY B. BERGADO all of legal ages, married, with residence and postal address at Brgy.
Cavite West, Palo, Leyte, after having been sworn to in accordance with law hereby depose and
state the following, THAT:

1. We are the legitimate and compulsory heirs of one REMEDIOS B. BERGADO

who was a retired teacher at Alangalang Elementary School, Alangalang, Leyte. Thus,
she was a member of Philippine Public School Teachers Association (PPSTA) and as
such she was issued an insurance policy;

2. Unfortunately, said Remedios died on June 26, 2014 at Tacloban City;

3. Our mother (Remedios) have been keeping the said Policy. However, the same
Policy was nowhere to be found. Due diligence was exercised in retrieving or finding the
said Policy but until this time it could not be found anymore and is deemed lost;

4. For the purpose of claiming benefits, the said Policy is supposed to be presented.
But since said Policy was lost we could not present the same anymore, Nonetheless, it
may be verified in the records of the company whether said Policy is still intact or had
been taken already. Thus, in lieu of the said Policy, we are executing this Affidavit of
Loss to attest the truth of the foregoing and to support the claims for benefits under said
Policy;

5. The said Policy has never been assigned, transferred or conveyed to any person,
company, association or corporation, nor does any party have a claim or interest over the
same;

6. We hereby waive all our rights and claims and liabilities whatsoever which may
arise out of or in connection with the said Policy;

IN WITNESS WHEREOF, we have hereunto set our signatures this ___ day of July 2014
at Palo, Leyte, Philippines.

NANCY BERGADO-FLORES MARIA ELENA BERGADO

HERMOSO
Affiant Affiant
US Army ID No. 1394421282 Driver’s License No. K01-12-001372
Valid until 2035 Jul 31 Valid Until 2014-12-21

DANNY B. BERGADO
Affiant
AFPSLAI ID No. 971182

SUBCRIBED AND SWORN TO before me, in the Municipality of Palo,

Leyte, this ____ day of July 2014 by the above affiants showing their
identification cards shown above.