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AffidavitofLoss PDF

This affidavit of loss was sworn by an individual who is a policyholder of Cocoplans, Incorporated. The individual held policy number [NUMBER] issued on [DATE]. However, the individual can no longer locate their copy of the policy contract after conducting a diligent search. The individual attests that the lost policy contract was not pledged or encumbered in any way. The purpose of this affidavit is to attest to the loss of the individual's policy contract with Cocoplans, Incorporated.

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101 views1 page

AffidavitofLoss PDF

This affidavit of loss was sworn by an individual who is a policyholder of Cocoplans, Incorporated. The individual held policy number [NUMBER] issued on [DATE]. However, the individual can no longer locate their copy of the policy contract after conducting a diligent search. The individual attests that the lost policy contract was not pledged or encumbered in any way. The purpose of this affidavit is to attest to the loss of the individual's policy contract with Cocoplans, Incorporated.

Uploaded by

Anonymous zXR0Zo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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AFFIDAVIT OF LOSS

I, ________________________________________, of legal age and a resident of


_________________________________________________________________ after having been sworn in
accordance with law, depose and state;

1. That I am a planholder of COCOPLANS, INCORPORATED having been issued Policy Contract Number
_______________.
2. The Policy Contract with the above account number has been issued to me on _______________________.
3. That when I looked for my copy of the said Policy Contract, I could not locate the same and diligent search
for it proved futile;
4. That the said Policy Contract has not been pledge, not encumbered in any way, and I shall hold
COCOPLANS, INCORPORATED harmless for any damage that may incurred be reason of the said Policy
Contract;
5. That, I am executing this affidavit to attest the loss of my Policy Contract.

IN WITNESS WHEREOF, I have hereunto set my hand this _______ day of ________________, ________.

______________________________
AFFIANT

Republic of the Philippines) S.S.


_____________________________)

Before me a Notary Public for in and for _____________________, Philippines, personally appeared
__________________ with Community Tax No. ______________________ issued at ___________________ on
_______ day of __________________, _______, known to me and to me known to be the same person who
executed the foregoing instrument and acknowledged to me that his/her free and voluntary act and deed.

IN WITNESS WHEREOF, I have hereunto set my and affixed my notarial seal in the ________________,
Philippines this _______ day of _____________.

Doc. No. : ___________


Page No. : ___________
Book No. : ___________
Series of : ___________

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