Sample Affidavit of Death for Insurance Claim

Republic of the Philippines )
City of Makati               ) S.S.


            I, LIZA S. DELA CRUZ of legal age, Filipino citizen, widow and presently residing at 3333 M. Ocampo Street, Pio del Pilar, Makati City, after having been duly sworn to in accordance with law, do hereby depose and say:

1.  That I am the widow of BENITO D. DELA CRUZ who died on July 30, 2013 in Quezon City because of head injuries sustained in a vehicular accident as per autopsy result conducted by Dr. Lito R. Santos;

2.  That per investigation of the Quezon City Police Station, my husband was driving along the northbound lane of EDSA  in front of Camp Aguinaldo in Quezon City when he was hit/bumped by a truck coming from the opposite direction; copy of the Traffic Investigation Report is hereto attached as Annex "A";

3.  That at the time of the incident, my husband was a duly licensed driver carrying Driver's License No. 123456 and was riding on a Toyota Innova, gray in color and with Plate No. XYZ-123 owned by me with Certificate of Registration No. 55667788;

4.  That I am executing this affidavit in support of my application for insurance claim with _____________, to attest to the truth of the foregoing, and for whatever legal purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 6th day of October 2013 at Makati City, Philippines.

                                                                                    LIZA S. DELA CRUZ

            SUBSCRIBED AND SWORN to before me this 6th day of October 2013 in the City of Makati, Philippines, affiant exhibiting to me her competent evidence of identity by way of Philippine Passport No. 12344 issued at Manila, Philippines on September 5, 2012.

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Series of 2013                                                             Notary Public