You are on page 1of 1

AFFIDAVIT I, ELEODORO B.

COMPRA, Filipino citizen, of legal age, married, and a resident of Basud, Camarines Norte, after having been duly sworn in accordance with law, hereby depose and say: That I am an Insurance Policy holder at Country Bankers Insurance Corporation with Insurance Policy No. 1001195; That on August 31, 2007, while cruising The National Highway at Bgy. Pagsangahan, Basud, Camarines Norte, I accidentally bumped into a Honda Wave 125 motorcycle which at that time driven by Romeo Pardo as shown in the Certification made by the Basud Municipal Station in Basud, Camarines Norte; That I am executing this affidavit to attest to the facts aforestated, and for the purpose to request Country Bankers Insurance Corporation to grant my Insurance Claims and to whatever legal purpose this may serve. IN WITNESS WHEREOF, I have hereunto affixed my signature this 15th day of November, 2007, at Daet, Camarines Norte. ___________________________ ELEODORO B. COMPRA REPUBLIC OF THE PHILIPPINES ) PROVINCE OF CAMARINES NORTE )SS. MUNICIPALITY OF D A E T ) SUBSCRIBED AND SWORN to before me this 15th day of November, 2007, in Daet, Camarines Norte.

Notary Public Doc. No. .........: Page No. .........; Book No. .........; Series of 2007.