REPUBLIC OF THE PHILIPPINES)

CITY OF ______________________) SS

AFFIDAVIT OF ACCIDENT

I, _____________________________, Filipino, of legal age, with

r e s i d e n c e 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 o’clock in the afternoon, I was driving along
Airport 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, 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 _____________,2017

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 _______