Affidavit OfLoss GSIS Policy

REPUBLIC OF THE PHILIPPINES) Province of ___________ ) S. S.S. Municipali! of________ ) "######## ########### ####" AFFIDAVIT OF LOSS

I$  ________________, Filipino$ Filipino$ of le%al a%e$ an& a re'i&en _______________$ _______________$ $ afer   (ein% &ul! 'orn o in accor&ance i* la$ *ere(! &epo'e an& 'ae+

T*a I a, *e 'a,e per'on e"ecuin% e"e cuin% *i' -ffi&avi -ffi&avi T*a I a, a %overn,en e,plo!ee an& a ,e,(er of *e /overn,en Service In'urance S!'e, 0/SIS) T*a (ein% a ,e,(er of *e /SIS$ I a' i''ue& (! *e /SIS a Polic! Conrac un&er CM  No. __________ T*a I u'e& o 1eep *e a(ove &ocu,en in'i&e our office a *e ______________ T*a i a' onl! recenl! *a I 'earc*e& for *e 'ai& Polic! Conrac (ecau'e ,! polic! alrea&! ,aure& (u I coul& no lon%er fin& *e 'a,e T*a &e'pie &ili%en 'earc* an& effor' o locae *e Polic! Conrac$ *e 'a,e coul& no  (e foun& 'uc* *a I no con'i&er i lo' (e!on& recover! -' 'uc*$ I a, e"ecuin% *i' -ffi&avi of Lo'' o ae' o *e ru* of *e fore%oin% an& for an! le%al purpo'e i ,a! 'erve. IN WITNESS WHEREOF$ I *ave *ereuno 'e ,! *an& *i' _______________ a  _________________.

 _________________  -ffian I2 NO. __________  SUBSCRIBED IBED AND  ______________  ______________________ _________. _.

SWO WOR RN

WITNESS MY HAND AND SEAL.

o

(efore

,e$

*i'

____________

a