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Affidavit of Loss - Baliga

Jimmy P. Baliga filed an affidavit of loss stating that he is a policy holder of a health insurance plan with Caritas Health Shield effective June 29, 2001 and was issued policy number E101-1028705. He kept the original insurance policy in an envelope in his home cabinet but recently discovered it was missing despite searching. He believes the policy is now lost beyond recovery. He signed the affidavit to attest to the truth of the statements regarding the lost insurance policy.

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288 views1 page

Affidavit of Loss - Baliga

Jimmy P. Baliga filed an affidavit of loss stating that he is a policy holder of a health insurance plan with Caritas Health Shield effective June 29, 2001 and was issued policy number E101-1028705. He kept the original insurance policy in an envelope in his home cabinet but recently discovered it was missing despite searching. He believes the policy is now lost beyond recovery. He signed the affidavit to attest to the truth of the statements regarding the lost insurance policy.

Uploaded by

sheryl
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Republic of the Philippines)

Province of Cagayan ) S.S.


Tuguegarao City )
x------------------------------------------x

AFFIDAVIT OF LOSS

I, JIMMY P. BALIGA, Filipino, of legal age, married and a resident of


Balzain Highway, Tuguegarao City, Cagayan after having been duly sworn to in
accordance with law, do hereby deposes and states, THAT:

1. I am a plan holder of health care insurance with Caritas Health


Shield which became effective on June 29, 2001;

2. As such I was issued the original policy which bears with it the
insurance no. E101-1028705;

3. Said insurance policy was placed along with other important


documents in an envelope and kept the same in a cabinet in my
house;

4. However, just lately, I was in shocked when I checked the cabinet


and found out that the insurance policy was missing;

5. Despite diligent search and efforts to locate the said insurance


policy, I could not find them such that I now believe that they are
now lost beyond recovery;

6. As such, I am executing this affidavit to attest to the veracity and


truthfulness of the foregoing statements.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day


of February 2017 in Tuguegarao City, Cagayan, Philippines.

JIMMY P. BALIGA
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of February 2017 in


Tuguegarao City, Cagayan, Philippines.

Doc. No._____
Page No. ____
Book No._____
Series of 2017.

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