REPUBLIC OF THE PHILIPPINES

PROVINCE OF CAPIZ
CITY OF ROXAS

AFFIDAVIT OF ACCIDENT
I, NOE L. GALIGAO, Filipino, of legal age, married and a resident of
Burgos Taft St., Roxas City, after being duty sworn to in accordance with
law hereby depose and say: that –

I am the husband of Antonia L. Galigao the registered owner of

a motor vehicle which is more particularly describes as follows:

Make: ISUZU ;
Model: WAGON ;
Motor No. 4JJ1NP8608 ;
Chassis No. MPAUCR85GFT001798 ;

On November 5, 2017 at around 12:05 o’clock in the

afternoon, while I was traversing the road to Jagnaya, Jamindan, Capiz, to
Sto. Rosario using said vehicle, the vehicle suddenly stepped on plowing
tools at the right side of the road and it titled towards said vehicle and hit
it;

As a result, said vehicle sustained heavy damage on the right

front bumper, right side doors, the front right side wheel and the right side
rear fender;

I am executing this affidavit to affirm the truth and veracity of

the foregoing facts and in support of our claim under the vehicle’s
insurance policy;

IN WITNESS WHEREOF, I HERUNTO AFFIXED MY SIGNATURE THIS ____

____________________, AT THE City of Roxas, Philippines.

Noe L. Galigao
Affiant

SUBSCRIBED AND SWORN to before me this ___________________

___, at the City of Roxas, Philippines

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