Republic of the Philippines)

) S.S.

Affidavit Of Death For Insurance Claim

            I, __________________ of legal age, Filipino citizen, widow and presently residing at

___________________, after having been duly sworn to in accordance with law, do hereby
depose and say:

1.  That I am the _______________________ who died on ___________ in ___________ because of

_____________________ as per autopsy result conducted by _______________;

2.  That per investigation of the ____________Police Station, my husband was driving along the
___________________ when he was hit/bumped by a _____________ coming from the opposite
direction; copy of the Traffic Investigation Report is hereto attached as Annex "A";

3.  That at the time of the incident, my husband was a duly licensed driver carrying Driver's
License No. ___________ and was riding on a _______________ and with Plate No__________ owned
by me with Certificate of Registration No. ______;

4.  That I am executing this affidavit in support of my application for insurance claim with
_____________, to attest to the truth of the foregoing, and for whatever legal purposes it may
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this ______________ at ___________,

Philippines.

                                                                                    __________________________
                                                                                                Affiant
                                                                                   

            SUBSCRIBED AND SWORN to before me this _________________ in the ______________,

Philippines, affiant exhibiting to me her competent evidence of identity by way of
____________________issued at Manila, Philippines on _____________________.

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Book No.: ______                                              
Series of 20___