REPUBLIC OF THE PHILIPPINES)

City of
)S.S
A F F I D A V I T OF VEHICULAR ACCIDENT
I, of legal age, Filipino citizen and a resident of, after being duly sworn to in
accordance with law, hereby depose and state:
That, on ____ at about ____________, I was driving a motor vehicle described
as follows:
Year/Make/Type
Motor No.
Serial No.
Plate No.
Owned by
Policy No.

:
:
:
:
:
:

That
while
I
was
driving
the
aforesaid
vehicle
along
_______________________________ a vehicular accident occurred in the following
manners:

That I have executed this affidavit to attest the truth of the aforementioned acts
under oath for insurance purposes.
IN WITNESS WHEREOF, I have hereunto set my hand this __________ day of
___________________ in the City of ______________________.

_____________________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of _________, 2012, affiant
exhibiting to me his/her residence certificate no. ________________ issued on
____________ at ____________.
NOTARY PUBLIC
Doc. No. ______
Page No. ______
Book No. ______
Series of 2012