Republic of the Philippines )

City of ________________ )

x-----------------------x

AFFIDAVIT OF LOSS

I, CRISSILLA LESLIE M. VITTO Filipino, of legal age,(single / married / widow),and a

resident of SANTOS AQUINO NAGPAYONG II, PASIG CITY after being sworn to in
accordance with law, depose and state:

1. That I am a currently employed in CONNEXT INSURANCE AGENCY under the

UNDERWRITING SECTION. As such, I handle the policy issuances of the FPG Insurance.

2. That on JANAURY 26, 2018 TO FEBRUARY 1, 2018 while printing the policies, the printer
jammed which caused the papers to crumple. That without any malice or intent, I disposed
such papers because it is already useless.

3. That on FEBRUARY 2, 2018, it came to my knowledge that such papers were necessary
for FPG to reconcile the Policy Nos., to wit:
35002 – ENDORSEMENT
MCAR - 148959 MCAR – 148960
MCAR – 148990 MCAR - 148998

4. That as much as I want to produce the same, it is no longer feasible because the same
were already disposed and beyond physical recovery.

5. That I am executing this Affidavit to attest to the truth of the forgoing and in support
of the claim against the insurer for the repair of the damage caused to my vehicle

__________________________
AFFIANT

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________

in______________________, Philippines.

DOC. NO. _____

BOOK NO. _____ NOTARY PUBLIC
PAGE NO. _____
SERIES OF 2018