Republic of the Philippines} Imus City, Cavite }s.

s AFFIDAVIT OF VEHICULAR ACCIDENT I, _________, of legal age,

married and with residence address at _________after having been duly sworn to according to law, hereby depose
and state: 1. That I am the registered owner of a motor vehicle which is specifically described as follows:
_________________________________ MODEL : MOTOR NO. : CHASSIS NO. : COLOR : PLATE NO. : 2. That said
motor vehicle figured in an accident on _____________, At about ______pm/am while I was driving it along
__________________ and as I was trying to turn left at the corner of __________________________, an
______________ with Plate No. ______ driven by a certain ____________ tried to overtake me in the inner
portion of that corner thus grazing and scraping the left hand fender liner, left hand side view mirror, dents in the
front and rear doors on the left hand side which thus sustained considerable damage to my said vehicle. 3. As we
were both in a hurry and I was still in my bedroom shorts as I was just about to bring my daughter to school, we
did not bother anymore to summon a policeman to record the accident; 4. That I am executing this affidavit in
order to attest to the truth of the foregoing circumstances and for the purpose of reporting the matter to my
insurance office for insurance claims. IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of
__________, 2013 at the City of __________________. ____________________ Affiant SUBSCRIBED AND SWORN
to before me this __ day of ___________ 2013, affiant exhibited a competent proof of their Identity: Govt. Issued
I.D. Valid Until __________________ _______________________ ________________ Notary Public Doc. No.
__________; Page No. __________; Book No. __________; Series of 2013.

(Affidavit of Damage to Vehicle Hitting a Post while Backing)

Republic of the Philippines)
Province of_________________) S.S.
City/Municipality of___________)
x------------x

AFFIDAVIT
I,____________,Filipino, of legal age,(single / married / widow),and a resident
of__________, Philippines, after being sworn to in accordance with law, depose and state:

1.That I am a duly licensed driver with Driver's License No._____________covered by DLR

No.___________, which is valid until___________.

2. That on___________, at around_______, I was driving a motor vehicle owned and

registered in my name which is more particularly described as follows:

Make____________ Motor No.:____________

Series:__________ Chassis No.:___________
Body Type:___________Plate No.:_____________
Year Model:___________MVRR No.:____________

3. That while I was slowly backing out of the driveway

along__________Street,____________,to park my car at the parking area of___________,
the aforementioned vehicle suddenly hit the post of the building from where I was backing
out and as a result the said vehicle sustained damage at its __________;

4. 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

IN WITNESS WHEREOF,I have hereunto set my hand this___________in___________,

Philippines.

AFFIANT
 (JURAT)

REPUBLIC OF THE PHILIPPINES)

CITY OF ______________________)

AFFIDAVIT OF ACCIDENT

I , _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , F i l i p i n o , o f l e g a l a g e , w i t h r e s i d e n c e address at
___________________________________________, after having been dulysworn to in accordance
with law, hereby, depose and say that:

I am the authorized driver of one motor vehicle which is particularly describedas follows:
MAKE AND MODEL :
SERIAL NUMBER :
MOTOR NUMBER :
PLATE NUMBER :

On January 24, 2013 at around four o’clock in the afternoon, I was driving alongAirport Road at Parañaque City
going southbound. In the same lane, a ten-wheeler truck was also traversing the road on my right side on a fast
speed. As the truck was very fast, Idid not immediately notice that it sideswiped the right side portion of my driven
vehicle.Unfortunately, I was not able to stop the driver of the truck nor get the plate number of the
truck. The accident happened so fast and went beyond my control.I am executing this affidavit to attest to the truth
of the foregoing statement andin support of my claims for reimbursement from the insurance company.

_____________________ AffiantSUBSCRIBED AND SWORN to before me this _______day of

_____________,20___ at ________________, Affiant exhibiting to me his/her Residence Certificate No./ Valid
Identification _____________________________ issued at _____________ on
_____________________. NOTARY PUBLICDoc. No. _______ Page No. _______ Book No._______ Series of
_______