REPUBLIC OF THE PHILIPPINES) CITY OF ______________________) AFFIDAVIT OF ACCIDENT I, _____________________________, Filipino, of legal age, with residence address at ___________________________________________,

after having been duly sworn to in accordance with law, hereby, depose and say that: I am the authorized driver of one motor vehicle which is particularly described as follows: MAKE AND MODEL SERIAL NUMBER MOTOR NUMBER PLATE NUMBER : : : :

On January 24, 2013 at around four oclock in the afternoon, I was driving along Airport Road at Paraaque 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, I did 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 and in support of my claims for reimbursement from the insurance company.

_____________________ Affiant

SUBSCRIBED 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 PUBLIC Doc. No. _______ Page No. _______ Book No._______ Series of _______