REPUBLIC OF THE PHILIPPINES

CITY/PROVINCE: ILOILO CITY / ILOILO

AFFIDAVIT OF LOSS
I, PIA C. BESA, 63 years o a!e, F"#"$"%o a%& '"() res"&e%*e a%& $os(a# a&&ress a(
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#a', )ere3y &e$ose a%& say4
,. T)a( I a5 ()e P#a%)o#&er o PHILIPPINES INTERNATIONAL LIFE
INSURANCE CO0PANY, INC., )a2"%! 3ee% "ss1e& a L"e/Pe%s"o%/
E&1*a("o%a# P#a% U%&er Co%(ra*( No.36-336.
.. T)a( I )a2e 3ee% "ss1e& a CERTIFICATE OF FULL PAY0ENT 7CFP8
a%& ()e sa"& Cer(""*a(e 'as "%a&2er(e%(#y #oss &1e (o F#as) F#oo& *a1se& 3y Ty$)oo% Fra%+ #as(
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