REPUBLIC OF THE PHILIPPINES)

CALAMBA CITY, LAGUNA ) S.S.

AFFIDAVIT OF CAR ACCIDENT

I, ANDRES SANDOVAL, Filipino citizen, of legal age, married to

SUSANA SANDOVAL, presently residing at Brgy. Ambulong, Batangas
City, after having sworn in accordance with law, depose and say:

THAT, I bought a private utility vehicle Hyunadai Grand V

Stares, Plate No. DAG 1788 with CR No. 292687441 and OR No.
1249594986 Metallic Gray 2018 Model;

THAT, this 19 November 2019 about nighttime I went to my son’s

doctor for a checkup. It was very dark due to the fact that there were no
lamp posts along the way.

While traversing the road I was surprised to hear a sound as if I hit

something. Then I stopped and checked, I noticed that there was a very
low barricade which cannot be immediately seen while driving.

That barricade had hit my bumper which caused a dent on it and

destroyed my car’s paint.

THAT, I am executing this affidavit to attest to the

truthfulness of the above facts to support my request for
REPLACEMENT/REPAIR of the damages incurred by Car
chargeable against my INSURANCE with Philippine British Assurance
Co., Inc. located at _____________________________________________________
under POLICY No. ____________________________ and other legal purpose
it may serve.

AFFIANT FURTHER SAYETH NOTH.

ANDRES SANDOVAL
Affiant

SUBSCRIBED AND SWORN to before me this 20TH day of

November 2019 at Calamba City, Laguna, affiant displaying his
DRIVER LICENSE NO.__________________ valid until ____________
with his digital picture and signature to prove his identity.

DOC NO. ;
PAGE NO. ;
BOOK NO. ;
SERIES OF 2019.